Provider Demographics
NPI:1528309655
Name:FERMIN, MA ROXANNE (OD)
Entity type:Individual
Prefix:DR
First Name:MA ROXANNE
Middle Name:
Last Name:FERMIN
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 1:11964 AVIATION BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90304
Mailing Address - Country:US
Mailing Address - Phone:310-536-9500
Mailing Address - Fax:844-272-8842
Practice Address - Street 1:11964 AVIATION BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90304
Practice Address - Country:US
Practice Address - Phone:310-536-9500
Practice Address - Fax:844-272-8842
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist