Provider Demographics
NPI:1013961457
Name:GHOHESTANI, MASOUD (OD)
Entity Type:Individual
Prefix:DR
First Name:MASOUD
Middle Name:
Last Name:GHOHESTANI
Suffix:
Gender:M
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 4174
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-4174
Mailing Address - Country:US
Mailing Address - Phone:812-926-4836
Mailing Address - Fax:812-926-4651
Practice Address - Street 1:100 SYCAMORE ESTATES DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IN
Practice Address - Zip Code:47001-1488
Practice Address - Country:US
Practice Address - Phone:812-926-4836
Practice Address - Fax:812-926-4651
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003027A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2278664Medicaid
IN201392310Medicaid
OH2278664Medicaid
INU75303Medicare UPIN