Provider Demographics
NPI:1356307516
Name:FARAHMAND, MEHRAK KHADAVI (OD)
Entity Type:Individual
Prefix:DR
First Name:MEHRAK
Middle Name:KHADAVI
Last Name:FARAHMAND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MEHRAK
Other - Middle Name:
Other - Last Name:KHADAVI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:63 S ROCKFORD DR STE 220
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85288-6226
Mailing Address - Country:US
Mailing Address - Phone:831-647-3900
Mailing Address - Fax:831-771-3966
Practice Address - Street 1:2 UPPER RAGSDALE DR STE B130
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-7842
Practice Address - Country:US
Practice Address - Phone:831-647-3900
Practice Address - Fax:831-771-3966
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11474152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0114740Medicaid
CASD0114740Medicaid
OP11474Medicare ID - Type Unspecified