Provider Demographics
NPI:1366521809
Name:ALDERSON, CHERYL EVELYN (OD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:EVELYN
Last Name:ALDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21098 BAKE PKWY
Mailing Address - Street 2:#110
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2163
Mailing Address - Country:US
Mailing Address - Phone:949-597-0104
Mailing Address - Fax:
Practice Address - Street 1:21098 BAKE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2163
Practice Address - Country:US
Practice Address - Phone:949-597-0104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12946152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01349074Medicare PIN
CACB582EMedicare PIN
CACB582EMedicare PIN