Provider Demographics
NPI:1568957678
Name:TAYONG, COREELIZA (OD)
Entity Type:Individual
Prefix:DR
First Name:COREELIZA
Middle Name:
Last Name:TAYONG
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 1:1602 W BENBOW ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3413
Mailing Address - Country:US
Mailing Address - Phone:858-335-4204
Mailing Address - Fax:
Practice Address - Street 1:14755 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3669
Practice Address - Country:US
Practice Address - Phone:818-464-1937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33950TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist