Provider Demographics
NPI:1528735693
Name:DEMIRI, STIVIA (OD)
Entity type:Individual
Prefix:DR
First Name:STIVIA
Middle Name:
Last Name:DEMIRI
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 1:419 FELLSWAY E
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-2326
Mailing Address - Country:US
Mailing Address - Phone:781-321-8229
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST STE 208
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4530
Practice Address - Country:US
Practice Address - Phone:781-395-9916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0133949152W00000X
MA5629152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT030.0133949OtherVERMONT LICENSE
MA5629OtherMASSACHUSETTS LICENSE