Provider Demographics
NPI:1003825621
Name:AZADI, SOROUSH BAHNAMIRI (OD)
Entity Type:Individual
Prefix:
First Name:SOROUSH
Middle Name:BAHNAMIRI
Last Name:AZADI
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 1:4211 S LAMAR BLVD
Mailing Address - Street 2:STE E-3
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7996
Mailing Address - Country:US
Mailing Address - Phone:512-916-4600
Mailing Address - Fax:
Practice Address - Street 1:4211 S LAMAR BLVD
Practice Address - Street 2:STE E-3
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7996
Practice Address - Country:US
Practice Address - Phone:512-916-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6642TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV03037Medicare UPIN
TX8L29366Medicare PIN