Provider Demographics
NPI:1891218673
Name:GETTAS, MARIAM ANNA
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:ANNA
Last Name:GETTAS
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 1:2426 SLEEPY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4711
Mailing Address - Country:US
Mailing Address - Phone:818-731-3405
Mailing Address - Fax:
Practice Address - Street 1:43927 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4758
Practice Address - Country:US
Practice Address - Phone:661-948-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33783TLG152WC0802X, 152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT33783TLGOtherOPTOMETRY