Provider Demographics
NPI:1447560388
Name:RAVEN, PEGAH (OD)
Entity type:Individual
Prefix:DR
First Name:PEGAH
Middle Name:
Last Name:RAVEN
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:PO BOX 103010
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91189-0147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2230 LYNN RD STE 102
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1920
Practice Address - Country:US
Practice Address - Phone:805-495-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004579152W00000X
CA14492TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist