=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043449655
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY DEMIRJIAN O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2009
-----------------------------------------------------
Last Update Date | 08/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17283 VENTURA BLVD
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-990-0300
-----------------------------------------------------
Fax | 818-990-4854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17283 VENTURA BLVD
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-990-0300
-----------------------------------------------------
Fax | 818-990-4854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 13710
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------