Provider Demographics
NPI:1184140915
Name:JALALAT, PARISA MARYAM (OD)
Entity type:Individual
Prefix:
First Name:PARISA
Middle Name:MARYAM
Last Name:JALALAT
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 1:1595 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8506
Mailing Address - Country:US
Mailing Address - Phone:714-399-0678
Mailing Address - Fax:714-276-6489
Practice Address - Street 1:8311 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90240-3928
Practice Address - Country:US
Practice Address - Phone:562-622-8700
Practice Address - Fax:562-622-1800
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33762152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT33762-TLGOtherOPTOMETRY