Provider Demographics
NPI:1932762861
Name:HEDAYAT, MAHDI (OD)
Entity Type:Individual
Prefix:
First Name:MAHDI
Middle Name:
Last Name:HEDAYAT
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 1:403 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5982
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-684-4924
Practice Address - Street 1:403 VONDERBURG DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5982
Practice Address - Country:US
Practice Address - Phone:813-681-1122
Practice Address - Fax:813-684-4924
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002333152W00000X
WAOD60878885152W00000X
FLOPC5769152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty