Provider Demographics
NPI:1851532147
Name:BAHRAM, HOORIA (OD)
Entity Type:Individual
Prefix:MRS
First Name:HOORIA
Middle Name:
Last Name:BAHRAM
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 1:18353 VANOWEN ST.
Mailing Address - Street 2:SUITE K
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-5498
Mailing Address - Country:US
Mailing Address - Phone:818-342-4768
Mailing Address - Fax:818-342-0063
Practice Address - Street 1:18353 VANOWEN ST.
Practice Address - Street 2:SUITE K
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-5498
Practice Address - Country:US
Practice Address - Phone:818-342-4768
Practice Address - Fax:818-342-0063
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4699/152W00000X
CAOPT13668152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3815Medicare UPIN
CABP048AMedicare PIN