Provider Demographics
NPI:1346232923
Name:VANESIAN, BRYAN DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DEAN
Last Name:VANESIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 PHELAN RD
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371-7675
Mailing Address - Country:US
Mailing Address - Phone:760-868-2020
Mailing Address - Fax:760-868-4225
Practice Address - Street 1:4355 PHELAN RD
Practice Address - Street 2:
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371-7675
Practice Address - Country:US
Practice Address - Phone:760-868-2020
Practice Address - Fax:760-868-4225
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9375T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0093750Medicaid
CASD0093750Medicaid