Provider Demographics
NPI:1497502751
Name:ANDIA, JEREMY (OD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:ANDIA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 N VENDOME ST APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-2856
Mailing Address - Country:US
Mailing Address - Phone:623-910-4209
Mailing Address - Fax:
Practice Address - Street 1:749 N VENDOME ST APT 3
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-2856
Practice Address - Country:US
Practice Address - Phone:623-910-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36156152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist