Provider Demographics
NPI:1609130095
Name:GHAZANFARI, ROSITA (OD)
Entity Type:Individual
Prefix:
First Name:ROSITA
Middle Name:
Last Name:GHAZANFARI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5442 LA SIERRA DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4108
Mailing Address - Country:US
Mailing Address - Phone:214-828-9900
Mailing Address - Fax:214-828-9901
Practice Address - Street 1:5442 LA SIERRA DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4108
Practice Address - Country:US
Practice Address - Phone:214-828-9900
Practice Address - Fax:214-828-9901
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8943152W00000X
OK2732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX393553201Medicaid
OK200507220AMedicaid