Provider Demographics
NPI:1730752650
Name:KAVOUSSI, KIYANA (OD)
Entity type:Individual
Prefix:
First Name:KIYANA
Middle Name:
Last Name:KAVOUSSI
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 1:7100 ALVERN ST APT 314
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3816
Mailing Address - Country:US
Mailing Address - Phone:901-626-0457
Mailing Address - Fax:
Practice Address - Street 1:12100 WILSHIRE BLVD STE 1275
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7143
Practice Address - Country:US
Practice Address - Phone:310-428-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35132152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009384Medicaid