Healthcare Provider Details

I. General information

NPI: 1407840960
Provider Name (Legal Business Name): LIZA F DIMARANAN O. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date: 03/25/2006
Reactivation Date: 03/31/2006

III. Provider practice location address

5026 PASSONS BLVD STE B
PICO RIVERA CA
90660-2800
US

IV. Provider business mailing address

5026 PASSONS BLVD STE B
PICO RIVERA CA
90660-2800
US

V. Phone/Fax

Practice location:
  • Phone: 562-948-1927
  • Fax: 562-948-4488
Mailing address:
  • Phone: 562-948-1927
  • Fax: 562-948-4488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11873T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: