Provider Demographics
NPI:1831240969
Name:TIRIVEEDHI, SUMAVAMSI (OD)
Entity type:Individual
Prefix:
First Name:SUMAVAMSI
Middle Name:
Last Name:TIRIVEEDHI
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 1:4321 LOS FELIZ BLVD APT 105
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2255
Mailing Address - Country:US
Mailing Address - Phone:323-660-8514
Mailing Address - Fax:
Practice Address - Street 1:9301 TAMPA AVE
Practice Address - Street 2:NORTHRIDGE FASHION CENTER #62
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-2503
Practice Address - Country:US
Practice Address - Phone:818-885-7300
Practice Address - Fax:818-709-2292
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU88015Medicare UPIN
CAWOP11531Medicare ID - Type Unspecified