Provider Demographics
NPI:1457969446
Name:STAPORNKUL, REBECCA (OD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:STAPORNKUL
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 1:8330 CASTANO PL
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-3805
Mailing Address - Country:US
Mailing Address - Phone:818-534-6604
Mailing Address - Fax:
Practice Address - Street 1:8330 CASTANO PL
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-3805
Practice Address - Country:US
Practice Address - Phone:818-534-6604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34885TLG152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes152W00000XEye and Vision Services ProvidersOptometrist