Provider Demographics
NPI:1184141814
Name:MIRYALA, SUDHESHNA
Entity type:Individual
Prefix:
First Name:SUDHESHNA
Middle Name:
Last Name:MIRYALA
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 1:8415 PIERCE DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3105
Mailing Address - Country:US
Mailing Address - Phone:714-470-8857
Mailing Address - Fax:
Practice Address - Street 1:8415 PIERCE DR
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3105
Practice Address - Country:US
Practice Address - Phone:714-470-8857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist