Provider Demographics
NPI:1154486090
Name:KAVOUSI, KAYGOSHTASB (OD)
Entity Type:Individual
Prefix:
First Name:KAYGOSHTASB
Middle Name:
Last Name:KAVOUSI
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:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-0363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 12 NORTH
Practice Address - Street 2:RIVERSIDE MALL, PEARLE VISION
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007112-1152W00000X
VA0618001619152W00000X
PAOET009046152W00000X
IA02380152W00000X
CO2566152W00000X
IDODP-100127152W00000X
UT63558749934152W00000X
HIOD-619152W00000X
WAOD00003937152W00000X
CAOPT12719-TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist