Basic Information
| Provider Information | |||||||||
| NPI: | 1841218518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASOPUST | ||||||||
| FirstName: | LENA | ||||||||
| MiddleName: | CYNTHIA | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11103 WEST AVE | ||||||||
| Address2: | 6 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782131370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246663 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 PLEASANT HILL RD | ||||||||
| Address2: | H10-1 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300964701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784750500 | ||||||||
| FaxNumber: | 6784750563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT001453 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.