Provider Demographics
NPI:1669294989
Name:AHMADI, BAHRAM
Entity type:Individual
Prefix:
First Name:BAHRAM
Middle Name:
Last Name:AHMADI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 S COAST HWY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2722
Mailing Address - Country:US
Mailing Address - Phone:949-715-7822
Mailing Address - Fax:949-264-1124
Practice Address - Street 1:729 S COAST HWY
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2722
Practice Address - Country:US
Practice Address - Phone:949-715-7822
Practice Address - Fax:949-264-1124
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD70586156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty