Provider Demographics
NPI:1649505611
Name:BUDNERO, MAIA J (OD)
Entity type:Individual
Prefix:
First Name:MAIA
Middle Name:J
Last Name:BUDNERO
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 1:330 N BRAND BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2308
Mailing Address - Country:US
Mailing Address - Phone:818-240-0890
Mailing Address - Fax:818-246-2540
Practice Address - Street 1:330 N BRAND BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2308
Practice Address - Country:US
Practice Address - Phone:818-240-0890
Practice Address - Fax:818-246-2540
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13847 TLG152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management