Provider Demographics
NPI:1609259068
Name:FANAIEYAN, AMELIA ANISA (OD)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:ANISA
Last Name:FANAIEYAN
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 1:38 SAINT STEPHENS DR
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-1950
Mailing Address - Country:US
Mailing Address - Phone:925-323-0000
Mailing Address - Fax:
Practice Address - Street 1:38 SAINT STEPHENS DR
Practice Address - Street 2:
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-1950
Practice Address - Country:US
Practice Address - Phone:925-323-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100340152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist