Provider Demographics
NPI:1962044404
Name:GEVORGYAN, MANEH (OD)
Entity Type:Individual
Prefix:DR
First Name:MANEH
Middle Name:
Last Name:GEVORGYAN
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 1:2759 HERMOSA AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1748
Mailing Address - Country:US
Mailing Address - Phone:617-257-3852
Mailing Address - Fax:
Practice Address - Street 1:845 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-3337
Practice Address - Country:US
Practice Address - Phone:818-864-6461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34434152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist