Provider Demographics
NPI:1720132251
Name:WALD, ALISSA SUE (OD)
Entity type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:SUE
Last Name:WALD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1545 ADAMS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3814
Mailing Address - Country:US
Mailing Address - Phone:714-545-9162
Mailing Address - Fax:714-241-1345
Practice Address - Street 1:1545 ADAMS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3814
Practice Address - Country:US
Practice Address - Phone:714-545-9162
Practice Address - Fax:714-241-1345
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9377TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7145459162Medicaid
CA7145459162Medicaid
CAU27399Medicare UPIN