Provider Demographics
NPI:1205983905
Name:DR S DAYYANI OD A PROF CORP
Entity type:Organization
Organization Name:DR S DAYYANI OD A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHROKH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAYYANI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-319-6122
Mailing Address - Street 1:322 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1312
Mailing Address - Country:US
Mailing Address - Phone:310-319-6122
Mailing Address - Fax:310-458-4799
Practice Address - Street 1:322 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1312
Practice Address - Country:US
Practice Address - Phone:310-319-6122
Practice Address - Fax:310-458-4799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT10307152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001450Medicaid
CAU51954Medicare UPIN
CAGSD001450Medicaid