Healthcare Provider Details

I. General information

NPI: 1891218673
Provider Name (Legal Business Name): MARIAM ANNA GETTAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 12/06/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43927 15TH ST W
LANCASTER CA
93534-4758
US

IV. Provider business mailing address

2426 SLEEPY HOLLOW DR
GLENDALE CA
91206-4711
US

V. Phone/Fax

Practice location:
  • Phone: 661-948-6310
  • Fax:
Mailing address:
  • Phone: 818-731-3405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT33783TLG
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPT33783TLG
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT33783TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: