Provider Demographics
NPI:1619377132
Name:DANESHVAR, ELHAM (OD)
Entity Type:Individual
Prefix:
First Name:ELHAM
Middle Name:
Last Name:DANESHVAR
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 1:140 MACOMB PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-5651
Mailing Address - Country:US
Mailing Address - Phone:586-464-1479
Mailing Address - Fax:586-464-1480
Practice Address - Street 1:819 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1403
Practice Address - Country:US
Practice Address - Phone:248-435-2189
Practice Address - Fax:248-435-2302
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist