Provider Demographics
NPI:1114093622
Name:KASANOFF, DAVID MARK (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:KASANOFF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7339 EL CAJON BLVD
Mailing Address - Street 2:G
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-7435
Mailing Address - Country:US
Mailing Address - Phone:619-465-7900
Mailing Address - Fax:619-839-3840
Practice Address - Street 1:7339 EL CAJON BLVD STE G
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-7435
Practice Address - Country:US
Practice Address - Phone:619-465-7900
Practice Address - Fax:619-465-1642
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA8755T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0087550Medicaid
CADB262ZMedicare PIN
CASD0087550Medicaid