Basic Information
| Provider Information | |||||||||
| NPI: | 1285302901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHANEM | ||||||||
| FirstName: | MANIA | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 FLYNN RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930125092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056733930 | ||||||||
| FaxNumber: | 8056593217 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S WELLS RD STE 225 | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930041382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056590250 | ||||||||
| FaxNumber: | 8056599275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2021 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT35021 | CA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.