Provider Demographics
NPI:1659532125
Name:BERKOVICH, MARIYA (OD)
Entity Type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:BERKOVICH
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 1:9201 W SUNSET BLVD STE 709
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3708
Mailing Address - Country:US
Mailing Address - Phone:310-275-5533
Mailing Address - Fax:310-275-5523
Practice Address - Street 1:9201 W SUNSET BLVD STE 709
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-3708
Practice Address - Country:US
Practice Address - Phone:310-275-5533
Practice Address - Fax:310-275-5523
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12941152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV08003Medicare UPIN