Provider Demographics
NPI:1538136460
Name:NISHITANI, BEVERLY (OD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:
Last Name:NISHITANI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BEVERLY
Other - Middle Name:ANN
Other - Last Name:YAMAMOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:417 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3427
Mailing Address - Country:US
Mailing Address - Phone:909-986-9951
Mailing Address - Fax:909-986-9812
Practice Address - Street 1:417 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3427
Practice Address - Country:US
Practice Address - Phone:909-986-9951
Practice Address - Fax:909-986-9812
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10183T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2480OtherDAVIS VISION PIN
CASD0101830Medicaid
CA9V12089OtherINDIVIDUAL IEHP PIN
CASD0101830Medicare PIN
CASD0101830Medicaid