Healthcare Provider Details

I. General information

NPI: 1508505835
Provider Name (Legal Business Name): HOVHANNES HOVHANNISYAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 S ALAMEDA ST STE G-29
VERNON CA
90058-2010
US

IV. Provider business mailing address

PO BOX 58125
VERNON CA
90058-0125
US

V. Phone/Fax

Practice location:
  • Phone: 323-231-0005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number35374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: