Provider Demographics
NPI:1710190251
Name:DR B KAMKAR OD A PROFESSIONAL OPTOMETRY CORP
Entity Type:Organization
Organization Name:DR B KAMKAR OD A PROFESSIONAL OPTOMETRY CORP
Other - Org Name:MODERN OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, OWNER, DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMKAR
Authorized Official - Suffix:
Authorized Official - Credentials:OD, QME
Authorized Official - Phone:818-500-8008
Mailing Address - Street 1:1104 E COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1309
Mailing Address - Country:US
Mailing Address - Phone:818-500-8008
Mailing Address - Fax:818-500-8075
Practice Address - Street 1:1104 E COLORADO ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1309
Practice Address - Country:US
Practice Address - Phone:818-500-8008
Practice Address - Fax:818-500-8075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8512TLG152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0085121Medicaid
CASD0085121Medicaid
CASD0085121Medicaid