Provider Demographics
NPI:1821386947
Name:ANSARI, SHORA MOBIN (OD)
Entity Type:Individual
Prefix:
First Name:SHORA
Middle Name:MOBIN
Last Name:ANSARI
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 1:1545 ADAMS AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3875
Mailing Address - Country:US
Mailing Address - Phone:714-545-9162
Mailing Address - Fax:
Practice Address - Street 1:1525 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3639
Practice Address - Country:US
Practice Address - Phone:949-645-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14238152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist