Provider Demographics
NPI:1770909657
Name:KASSAWAT, JANICE (OD)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:KASSAWAT
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 1:17900 NEWHOPE ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5422
Mailing Address - Country:US
Mailing Address - Phone:714-444-4225
Mailing Address - Fax:714-444-4225
Practice Address - Street 1:17900 NEWHOPE ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5422
Practice Address - Country:US
Practice Address - Phone:714-444-4225
Practice Address - Fax:714-444-4225
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9721 TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist