Provider Demographics
NPI:1801024716
Name:PEZESHK, SAMIN (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMIN
Middle Name:
Last Name:PEZESHK
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4553 N LOOP 1604 W STE 1225
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-1365
Practice Address - Country:US
Practice Address - Phone:210-251-2372
Practice Address - Fax:210-251-2231
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8342-T152W00000X
IN18003589A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200953050Medicaid
IN252690GMedicare PIN
IN160450013Medicare PIN
IN452570026Medicare PIN
P00780734Medicare PIN