Basic Information
| Provider Information | |||||||||
| NPI: | 1508065020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEJIA | ||||||||
| FirstName: | GUADALUPE | ||||||||
| MiddleName: | ANGELICA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY STE 290 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022178221 | ||||||||
| FaxNumber: | 5022175056 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E MUHAMMAD ALI BLVD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525466 | ||||||||
| FaxNumber: | 5028524947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 10/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 007185 | NY | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1750DT | KY | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 7100114440 | 05 | KY | MEDICAID |