Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 10611T | CA |
NPI | 1003944968 |
---|---|
Provider Name | Dr. Lori Johnson Bende |
First Address | San Diego, CA 92122-2522 |
Second Address | San Diego, CA 92122-2522 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
13089 | MEDICAL EYE SERVICES PROV (01) | CA |
50322 | AVP SAFEGURAD PROVIDER NU (01) | CA |
OP10611 | (02) | CA |
SD0106110 | (05) | CA |