Provider Demographics
NPI:1962410225
Name:BARROSO-MAINENTI, LUIZA H (OD)
Entity type:Individual
Prefix:DR
First Name:LUIZA
Middle Name:H
Last Name:BARROSO-MAINENTI
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 1:1260 N DUTTON AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4659
Mailing Address - Country:US
Mailing Address - Phone:707-524-2442
Mailing Address - Fax:707-524-2438
Practice Address - Street 1:1260 N DUTTON AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4659
Practice Address - Country:US
Practice Address - Phone:707-524-2442
Practice Address - Fax:707-524-2438
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10374 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT10374TOtherOPTOMETRY LICENSE
CAMB0653104OtherDEA NUMBER
CAU77996Medicare UPIN
CAOPT10374TOtherOPTOMETRY LICENSE