Provider Demographics
NPI:1588709190
Name:SARAJIAN, IDA A (OD)
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:A
Last Name:SARAJIAN
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 1:330 N BRAND BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203
Mailing Address - Country:US
Mailing Address - Phone:818-241-4921
Mailing Address - Fax:818-241-0468
Practice Address - Street 1:330 N BRAND BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203
Practice Address - Country:US
Practice Address - Phone:818-241-4921
Practice Address - Fax:818-241-0468
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10412T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0104120Medicaid
CAWOP10412AOtherPPIN
U78287Medicare UPIN
CAWOP10412AOtherPPIN