NPIMap

Organization Active NPI

Marshall B. Ketchum University

  • Optometrist
  • Anaheim, CA
National Provider Identifier
1720101876
Registry record updated Sep 20, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
MARSHALL B. KETCHUM UNIVERSITY
Practice address
5460 E la Palma Ave
Anaheim, CA 92807-2023
Phone
(714) 463-7500
Fax
(714) 992-7811
NPI assigned
Apr 6, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 20, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mark Nakano, O.D.NPI 1821072133
Title
Associate Dean of Clinics
Phone
(714) 463-7504

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X Primary

Addresses

Primary practice location

5460 E la Palma Ave
Anaheim, CA 92807-2023

Mailing address

5460 E la Palma Ave
Anaheim, CA 92807-2023
Phone (714) 463-7500

Other identifiers 2

IdentifierTypeStateIssuer
CP8428OtherCARAILROAD
ZZT11708FMedicaidCA

Other names 1

  • University Eye Center Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040224000463 CA Part B Supplier - Clinic/Group Practice 9739075177 Receives reassigned benefits from 129 practitioners
2 other NPIs on this enrollment
Practice locations: Anaheim, CA; Los Angeles, CA

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

2575 Yorba Linda Blvd
Fullerton, CA 92831
Phone (714) 449-7400

Practitioners & affiliated clinicians

Practitioners 130

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 130

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1474329600000",
    "number": "1720101876",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5460 E LA PALMA AVE",
            "city": "ANAHEIM",
            "state": "CA",
            "postal_code": "928072023",
            "telephone_number": "714-463-7500",
            "fax_number": "714-992-7811"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5460 E LA PALMA AVE",
            "city": "ANAHEIM",
            "state": "CA",
            "postal_code": "928072023",
            "telephone_number": "714-463-7500",
            "fax_number": "714-992-7811"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARSHALL B. KETCHUM UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-06",
        "last_updated": "2016-09-20",
        "status": "A",
        "authorized_official_last_name": "NAKANO",
        "authorized_official_first_name": "MARK",
        "authorized_official_title_or_position": "ASSOCIATE DEAN OF CLINICS",
        "authorized_official_telephone_number": "714-463-7504",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD",
            "identifier": "CP8428",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZT11708F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "University Eye Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Anaheim, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.