Provider Demographics
NPI:1336514694
Name:ESMAEILI, MICHELLE MARYAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARYAM
Last Name:ESMAEILI
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 1:870 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3531
Mailing Address - Country:US
Mailing Address - Phone:626-390-3141
Mailing Address - Fax:
Practice Address - Street 1:10740 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3862
Practice Address - Country:US
Practice Address - Phone:909-942-3030
Practice Address - Fax:909-466-4941
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33755TLG152W00000X
OHOPT6428152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist