Provider Demographics
NPI:1932205226
Name:IRAHETA, DIANA ISABEL (OD)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:ISABEL
Last Name:IRAHETA
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 1:40386 AMESBURY LN
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4432
Mailing Address - Country:US
Mailing Address - Phone:310-259-5310
Mailing Address - Fax:
Practice Address - Street 1:30668 BENTON RD # B-101
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92696
Practice Address - Country:US
Practice Address - Phone:951-926-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13168152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist