Provider Demographics
NPI:1437422185
Name:MERCEDEH MOTAMENI, O.D., AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:MERCEDEH MOTAMENI, O.D., AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MERCEDEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTAMENI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-391-6311
Mailing Address - Street 1:4125 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4706
Mailing Address - Country:US
Mailing Address - Phone:310-391-6311
Mailing Address - Fax:310-390-1874
Practice Address - Street 1:4125 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4706
Practice Address - Country:US
Practice Address - Phone:310-391-6311
Practice Address - Fax:310-390-1874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9453T152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0094530Medicaid
CASD0094530Medicaid
CAFU109AMedicare PIN