MEDICARE: DR. KIUMARS AJDARI O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT 9889	CA

General Provider Information

NPI Number	:	1396804746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIUMARS AJDARI O.D.

Provider Business Mailing Address
First Line	:	3634 SAN PABLO DAM RD
Second Line	:
City	:	EL SOBRANTE
State	:	CA
Zip	:	94803-2730
Country	:	US
Telephone Number	:	510-222-6567
Fax Number	:	510-222-2161

Provider Business Practice Location Address
First Line	:	3634 SAN PABLO DAM RD
Second Line	:
City	:	EL SOBRANTE
State	:	CA
Zip	:	94803-2730
Country	:	US
Telephone Number	:	510-222-6567
Fax Number	:	510-222-2161

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	11/16/2007

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