Provider Demographics
NPI:1790461390
Name:AL-KHAZRAJI, SAYF
Entity Type:Individual
Prefix:
First Name:SAYF
Middle Name:
Last Name:AL-KHAZRAJI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2784 E ROCKWELD PATH
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4161
Mailing Address - Country:US
Mailing Address - Phone:773-766-2855
Mailing Address - Fax:
Practice Address - Street 1:800 E ATWATER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3635
Practice Address - Country:US
Practice Address - Phone:812-855-4447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004428A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist