Provider Demographics
NPI:1225070600
Name:EYVAZZADEH, BENICA (OD)
Entity Type:Individual
Prefix:
First Name:BENICA
Middle Name:
Last Name:EYVAZZADEH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 ROLLING OAKS DR
Mailing Address - Street 2:102
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1275
Mailing Address - Country:US
Mailing Address - Phone:805-497-3744
Mailing Address - Fax:805-497-1663
Practice Address - Street 1:351 ROLLING OAKS DR
Practice Address - Street 2:102
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1275
Practice Address - Country:US
Practice Address - Phone:805-497-3744
Practice Address - Fax:805-497-1663
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP10222GOtherDMERC
CAU51557Medicare UPIN
CAWOP10222GOtherDMERC