Provider Demographics
NPI:1003887522
Name:KHAZRAEE, FARZAD A (OD)
Entity Type:Individual
Prefix:DR
First Name:FARZAD
Middle Name:A
Last Name:KHAZRAEE
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:HC 3 BOX 31694
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-9495
Mailing Address - Country:US
Mailing Address - Phone:787-431-3311
Mailing Address - Fax:
Practice Address - Street 1:PLAZA ISABELA LOCAL 265
Practice Address - Street 2:3535 AVE. MILITAR
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662-5909
Practice Address - Country:US
Practice Address - Phone:787-589-8334
Practice Address - Fax:787-589-8334
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2022-08-24
Deactivation Date:2020-02-25
Deactivation Code:
Reactivation Date:2020-05-04
Provider Licenses
StateLicense IDTaxonomies
PR496-302152W00000X
PR496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRHSS378AMedicaid