Provider Demographics
NPI:1639251374
Name:MEGHDADI, PANTEA (OD)
Entity Type:Individual
Prefix:
First Name:PANTEA
Middle Name:
Last Name:MEGHDADI
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 1:18449 BROOKHURST ST STE 6
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6751
Mailing Address - Country:US
Mailing Address - Phone:714-963-2111
Mailing Address - Fax:
Practice Address - Street 1:18449 BROOKHURST ST STE 6
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6751
Practice Address - Country:US
Practice Address - Phone:714-963-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12524T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV07679Medicare UPIN
CAWOP12524AMedicare ID - Type Unspecified