Provider Demographics
NPI:1982750196
Name:KALOUSTIAN, TAMAR TANIA (OD)
Entity type:Individual
Prefix:DR
First Name:TAMAR
Middle Name:TANIA
Last Name:KALOUSTIAN
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 1:13903 OTSEGO ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-1222
Mailing Address - Country:US
Mailing Address - Phone:818-400-0007
Mailing Address - Fax:323-936-5153
Practice Address - Street 1:6333 W 3RD ST STE 708
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-3176
Practice Address - Country:US
Practice Address - Phone:323-936-5140
Practice Address - Fax:323-936-5153
Is Sole Proprietor?:No
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11156T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD011560Medicaid