Provider Demographics
NPI:1285726877
Name:TERUO WATANABE, O.D., INC.
Entity type:Organization
Organization Name:TERUO WATANABE, O.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERUO
Authorized Official - Middle Name:
Authorized Official - Last Name:WATANABE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-912-3937
Mailing Address - Street 1:18045 GALE AVE
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91748-1245
Mailing Address - Country:US
Mailing Address - Phone:626-912-3937
Mailing Address - Fax:626-913-8869
Practice Address - Street 1:18045 GALE AVE
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748-1245
Practice Address - Country:US
Practice Address - Phone:626-912-3937
Practice Address - Fax:626-913-8869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5612T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFV512AOtherGROUP
CASD0056121Medicaid
CAT70050Medicare UPIN
CA0837360001Medicare NSC
CAFV512AMedicare PIN