Provider Demographics
NPI:1598024622
Name:LEILA AHMADI OD, APC, AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:LEILA AHMADI OD, APC, AN OPTOMETRIC CORPORATION
Other - Org Name:LEILA AHMADI OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMADI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-489-2300
Mailing Address - Street 1:26800 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE #308
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6384
Mailing Address - Country:US
Mailing Address - Phone:949-489-2300
Mailing Address - Fax:949-489-2301
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE #308
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-489-2300
Practice Address - Fax:949-489-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10838TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAQ5288Medicare PIN