Provider Demographics
NPI:1891033825
Name:FADAVI, ROUSHANAK (OD)
Entity Type:Individual
Prefix:DR
First Name:ROUSHANAK
Middle Name:
Last Name:FADAVI
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 1:30212 TOMAS STE 170
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2174
Mailing Address - Country:US
Mailing Address - Phone:949-589-0767
Mailing Address - Fax:
Practice Address - Street 1:4 ARCATA
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-5138
Practice Address - Country:US
Practice Address - Phone:201-725-9285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14103T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management