Provider Demographics
NPI:1306906789
Name:MACUDZINSKI, NEAL W (OD)
Entity type:Individual
Prefix:DR
First Name:NEAL
Middle Name:W
Last Name:MACUDZINSKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3689 MIDWAY DR.
Mailing Address - Street 2:STE. D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110
Mailing Address - Country:US
Mailing Address - Phone:619-523-9990
Mailing Address - Fax:619-523-2176
Practice Address - Street 1:3689 MIDWAY DR.
Practice Address - Street 2:STE. D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110
Practice Address - Country:US
Practice Address - Phone:619-523-9990
Practice Address - Fax:619-523-2176
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9038152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU13904Medicare UPIN