Provider Demographics
NPI:1588143739
Name:DE JESUS, MELINDA THOMAS (OD, MS)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:THOMAS
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:GINEL
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2604 S MOORLAND PL
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1936
Mailing Address - Country:US
Mailing Address - Phone:805-889-1217
Mailing Address - Fax:
Practice Address - Street 1:248 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2147
Practice Address - Country:US
Practice Address - Phone:626-359-1213
Practice Address - Fax:626-359-1225
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT34028TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist