Provider Demographics
NPI:1699198457
Name:AVETISYAN, SUSANNA
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:AVETISYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13739 RIVERSIDE DR STE A
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2417
Mailing Address - Country:US
Mailing Address - Phone:818-995-7989
Mailing Address - Fax:818-995-7975
Practice Address - Street 1:13739 RIVERSIDE DR STE A
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2417
Practice Address - Country:US
Practice Address - Phone:818-995-7989
Practice Address - Fax:818-995-7975
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
148397156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician