Provider Demographics
NPI:1609968130
Name:GHADIMI, GITA (OPTOMETRIST)
Entity Type:Individual
Prefix:
First Name:GITA
Middle Name:
Last Name:GHADIMI
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15333 CULVER DR
Mailing Address - Street 2:SUITE 690
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3078
Mailing Address - Country:US
Mailing Address - Phone:949-552-4271
Mailing Address - Fax:949-552-0321
Practice Address - Street 1:15333 CULVER DR
Practice Address - Street 2:SUITE 690
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3078
Practice Address - Country:US
Practice Address - Phone:949-552-4271
Practice Address - Fax:949-552-0321
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12177T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU94195Medicare UPIN