Provider Demographics
NPI:1427232586
Name:GHAVAMI, CIA (OD)
Entity Type:Individual
Prefix:DR
First Name:CIA
Middle Name:
Last Name:GHAVAMI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:CIA
Other - Middle Name:
Other - Last Name:GHAVAMI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:11025 SW 15TH MNR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-7140
Mailing Address - Country:US
Mailing Address - Phone:305-892-8555
Mailing Address - Fax:305-892-5007
Practice Address - Street 1:11025 SW 15TH MNR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-7140
Practice Address - Country:US
Practice Address - Phone:305-892-8555
Practice Address - Fax:305-892-5007
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3114152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU71841Medicare UPIN