Provider Demographics
NPI:1396804746
Name:AJDARI, KIUMARS (OD)
Entity type:Individual
Prefix:DR
First Name:KIUMARS
Middle Name:
Last Name:AJDARI
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 1:3634 SAN PABLO DAM RD
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-2730
Mailing Address - Country:US
Mailing Address - Phone:510-222-6567
Mailing Address - Fax:510-222-2161
Practice Address - Street 1:3634 SAN PABLO DAM RD
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-2730
Practice Address - Country:US
Practice Address - Phone:510-222-6567
Practice Address - Fax:510-222-2161
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9889152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU66510Medicare UPIN