Provider Demographics
NPI:1760479497
Name:CARNEVALI, TONY (OD)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:
Last Name:CARNEVALI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-1307
Mailing Address - Country:US
Mailing Address - Phone:323-234-9137
Mailing Address - Fax:323-235-6203
Practice Address - Street 1:3916 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-1307
Practice Address - Country:US
Practice Address - Phone:323-234-9137
Practice Address - Fax:323-235-6203
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5827TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT11740FMedicaid
CAWOP 5827AMedicare ID - Type Unspecified
CAT 70065Medicare UPIN
CAWY1110Medicare ID - Type UnspecifiedGROUP NUMBER