Provider Demographics
NPI:1043449655
Name:DEMIRJIAN, MARY (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:DEMIRJIAN
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 1:17283 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4007
Mailing Address - Country:US
Mailing Address - Phone:818-990-0300
Mailing Address - Fax:818-990-4854
Practice Address - Street 1:17283 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4007
Practice Address - Country:US
Practice Address - Phone:818-990-0300
Practice Address - Fax:818-990-4854
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13710152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1140139Medicaid
CA8495739Medicaid
CA1366744856OtherGROUP NPI
CAEH745AMedicare PIN
CA1140139Medicaid