Provider Demographics
NPI:1730101833
Name:GOLBAHAR, BAHAREH (OD)
Entity Type:Individual
Prefix:DR
First Name:BAHAREH
Middle Name:
Last Name:GOLBAHAR
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 1:15519 ADAGIO CT
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1501
Mailing Address - Country:US
Mailing Address - Phone:310-440-3416
Mailing Address - Fax:310-208-6831
Practice Address - Street 1:1059 GAYLEY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3401
Practice Address - Country:US
Practice Address - Phone:310-208-3031
Practice Address - Fax:310-208-6831
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91571Medicare UPIN
CAW0P11882AMedicare PIN