Provider Demographics
NPI:1255044061
Name:KHATRI, SOPHIA RAZIUDDIN (OD)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:RAZIUDDIN
Last Name:KHATRI
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 1:2129 IVY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60192-4154
Mailing Address - Country:US
Mailing Address - Phone:219-512-0685
Mailing Address - Fax:
Practice Address - Street 1:4801 1ST AVE SE SPC 1
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3213
Practice Address - Country:US
Practice Address - Phone:319-393-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA117945152W00000X
COOPT.0003878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist