Provider Demographics
NPI:1942226022
Name:MAGDATO, MICHAEL D (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:MAGDATO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5237 ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1308
Mailing Address - Country:US
Mailing Address - Phone:909-625-6567
Mailing Address - Fax:909-399-9048
Practice Address - Street 1:5237 ARROW HWY
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1308
Practice Address - Country:US
Practice Address - Phone:909-625-6567
Practice Address - Fax:909-399-9048
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11921152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0119210Medicare PIN