Provider Demographics
NPI:1962244582
Name:DECIERDO, MARANDA HEATHER (OD)
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:HEATHER
Last Name:DECIERDO
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 1:324 MONTE CARLO AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-3719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6247 JARVIS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-1212
Practice Address - Country:US
Practice Address - Phone:510-494-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist