Provider Demographics
NPI:1437312832
Name:BRYAN D. VANESIAN OD A PROFESSIONAL OPTOMETRY CORPORATION
Entity Type:Organization
Organization Name:BRYAN D. VANESIAN OD A PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:VANESIAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-868-2020
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRYAN D. VANESIAN OD A PROFESSIONAL OPTOMETRY CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-07
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9375T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0093750Medicaid
CASD0093750Medicare PIN
CAU22963Medicare UPIN
CA5847630001Medicare NSC