Healthcare Provider Details

I. General information

NPI: 1740443480
Provider Name (Legal Business Name): ANDREA YIASEMIS O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 BARBARA AVE
MOUNTAIN VIEW CA
94040-3018
US

IV. Provider business mailing address

912 BARBARA AVE
MOUNTAIN VIEW CA
94040-3018
US

V. Phone/Fax

Practice location:
  • Phone: 530-219-5623
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13383T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: