Provider Demographics
NPI:1700071834
Name:JEDRUSIAK, MELANIE KIM (OD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:KIM
Last Name:JEDRUSIAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1141 W AVENUE L
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-7077
Mailing Address - Country:US
Mailing Address - Phone:661-945-0710
Mailing Address - Fax:661-802-4495
Practice Address - Street 1:1141 W AVENUE L
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-7077
Practice Address - Country:US
Practice Address - Phone:661-945-0710
Practice Address - Fax:661-802-4495
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11664T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist