Provider Demographics
NPI:1689343477
Name:THAVARAJAH, ANTONIETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIETTE
Middle Name:
Last Name:THAVARAJAH
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 1:6 PEBBLESTONE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BRAMPTON
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L6X4M3
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2810 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-9419
Practice Address - Country:US
Practice Address - Phone:716-834-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009448152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist