Basic Information
Provider Information
NPI: 1538647979
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ISLAM
FirstName: FARIA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: OD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6249 FILLY CT
Address2:  
City: RANCHO CUCAMONGA
State: CA
PostalCode: 917399590
CountryCode: US
TelephoneNumber: 9097628216
FaxNumber:  
Practice Location
Address1: 4560 E CESAR E CHAVEZ AVE
Address2:  
City: LOS ANGELES
State: CA
PostalCode: 900221117
CountryCode: US
TelephoneNumber: 3239809900
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/28/2018
LastUpdateDate: 07/28/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X34019TLGCAY Eye and Vision Services ProvidersOptometrist 

No ID Information.


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