Provider Demographics
NPI:1679728927
Name:ESTRADA, VIRGINIA (OD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:ESTRADA
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 1:4403 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2413
Mailing Address - Country:US
Mailing Address - Phone:323-232-1234
Mailing Address - Fax:323-232-3789
Practice Address - Street 1:4403 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2413
Practice Address - Country:US
Practice Address - Phone:323-232-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-28
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13662152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADT778ZMedicare PIN