Provider Demographics
NPI:1205878634
Name:KHRAISHI, TARIQ TAHIR (OD)
Entity type:Individual
Prefix:DR
First Name:TARIQ
Middle Name:TAHIR
Last Name:KHRAISHI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1907 DUFOUR AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-1307
Mailing Address - Country:US
Mailing Address - Phone:310-864-9323
Mailing Address - Fax:
Practice Address - Street 1:317 W PACIFIC COAST HWY STE B
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-2542
Practice Address - Country:US
Practice Address - Phone:424-264-5821
Practice Address - Fax:424-264-5886
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12311T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist