Healthcare Provider Details

I. General information

NPI: 1356911846
Provider Name (Legal Business Name): MICHAELA YACCOBI-MENASHERIAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 01/21/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 S CARILLO AVE STE 105
LOS ANGELES CA
90048
US

IV. Provider business mailing address

27271 LAS RAMBLAS STE 210
MISSION VIEJO CA
92691-8041
US

V. Phone/Fax

Practice location:
  • Phone: 323-954-5800
  • Fax:
Mailing address:
  • Phone: 949-652-7233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: