Provider Demographics
NPI:1346334166
Name:JALALI, AMIR SAHBA (OD)
Entity Type:Individual
Prefix:DR
First Name:AMIR
Middle Name:SAHBA
Last Name:JALALI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:340 KELLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3811
Mailing Address - Country:US
Mailing Address - Phone:573-582-1234
Mailing Address - Fax:573-582-1212
Practice Address - Street 1:340 KELLEY PKWY
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3811
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:573-582-1212
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001006508152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013984Medicare ID - Type Unspecified
MOU61249Medicare UPIN