Provider Demographics
NPI:1467661355
Name:MOHANA, TAREK (OD)
Entity Type:Individual
Prefix:DR
First Name:TAREK
Middle Name:
Last Name:MOHANA
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 1:1141 W AVENUE L
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-7077
Mailing Address - Country:US
Mailing Address - Phone:773-531-6088
Mailing Address - Fax:661-802-4495
Practice Address - Street 1:1141 W AVENUE L
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-7077
Practice Address - Country:US
Practice Address - Phone:773-531-6088
Practice Address - Fax:661-802-4495
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12756T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU92304Medicare UPIN
ILL93913Medicare ID - Type UnspecifiedMEMBER #