Provider Demographics
NPI:1457887085
Name:OMIDGHAEMI, SEPIDEH (OD)
Entity type:Individual
Prefix:
First Name:SEPIDEH
Middle Name:
Last Name:OMIDGHAEMI
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 1:3817 LOCKERBIE CT
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1024
Mailing Address - Country:US
Mailing Address - Phone:818-640-2646
Mailing Address - Fax:
Practice Address - Street 1:1605 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1402
Practice Address - Country:US
Practice Address - Phone:818-640-2646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9143T152W00000X
CA33826TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist