Provider Demographics
NPI:1841343647
Name:MOTAMENI, MERCEDEH (OD)
Entity type:Individual
Prefix:DR
First Name:MERCEDEH
Middle Name:
Last Name:MOTAMENI
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 1:4125 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4706
Mailing Address - Country:US
Mailing Address - Phone:310-391-6311
Mailing Address - Fax:310-390-1874
Practice Address - Street 1:4125 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4706
Practice Address - Country:US
Practice Address - Phone:310-391-6311
Practice Address - Fax:310-390-1874
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9453T152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0094530Medicaid
CAOP9453Medicare ID - Type Unspecified
CASD0094530Medicaid