Provider Demographics
NPI:1538647979
Name:ISLAM, FARIA (OD)
Entity Type:Individual
Prefix:
First Name:FARIA
Middle Name:
Last Name:ISLAM
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 1:6249 FILLY CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9590
Mailing Address - Country:US
Mailing Address - Phone:909-762-8216
Mailing Address - Fax:
Practice Address - Street 1:4560 E CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1117
Practice Address - Country:US
Practice Address - Phone:323-980-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34019TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist