Provider Demographics
NPI:1689312092
Name:CARIM-SANNI, RIDWAN (OD)
Entity Type:Individual
Prefix:
First Name:RIDWAN
Middle Name:
Last Name:CARIM-SANNI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 AIRPORT RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6493
Mailing Address - Country:US
Mailing Address - Phone:347-200-6213
Mailing Address - Fax:
Practice Address - Street 1:1248 WATERBURY RD
Practice Address - Street 2:
Practice Address - City:STOWE
Practice Address - State:VT
Practice Address - Zip Code:05672-4658
Practice Address - Country:US
Practice Address - Phone:802-253-6322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT030.0133965152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program