Provider Demographics
NPI:1427085059
Name:YOO, CARMEN JAN (OD)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:JAN
Last Name:YOO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:JAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1319 S HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-3001
Mailing Address - Country:US
Mailing Address - Phone:714-758-0185
Mailing Address - Fax:714-758-0759
Practice Address - Street 1:1319 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-3001
Practice Address - Country:US
Practice Address - Phone:714-758-0185
Practice Address - Fax:714-758-0759
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA11663T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0116630Medicaid
CAOP11663Medicare ID - Type Unspecified
CASD0116630Medicaid