Basic Information
| Provider Information | |||||||||
| NPI: | 1851404040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATANABE | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 REMITTANCE DR | ||||||||
| Address2: | DEPT 6008 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606756008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622821419 | ||||||||
| FaxNumber: | 5629204642 | ||||||||
| Practice Location | |||||||||
| Address1: | 4476 TWEEDY BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH GATE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902806359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235639499 | ||||||||
| FaxNumber: | 3235639056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT7702T | CA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 7702T | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | SD007020 | 05 | CA | MEDICAID | SD0077020 | 05 | CA | MEDICAID | 410046776 | 01 | CA | MEDICARE RAILROAD | OTHER | 00OPT7702T0 | 01 | CA | BLUE SHIELD | OTHER | 410046776 | 01 | CA | RAILROAD MEDICARE | OTHER |