Provider Demographics
NPI:1336218445
Name:CERVINSKI, THERESA M (OD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:M
Last Name:CERVINSKI
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 1:19530 VAN BUREN BLVD
Mailing Address - Street 2:G8
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-9455
Mailing Address - Country:US
Mailing Address - Phone:951-656-0500
Mailing Address - Fax:
Practice Address - Street 1:19530 VAN BUREN BLVD
Practice Address - Street 2:G8
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-9455
Practice Address - Country:US
Practice Address - Phone:951-656-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2562ATI152W00000X, 152WV0400X
NV639152W00000X
CA13242152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU67293Medicare UPIN