Healthcare Provider Details

I. General information

NPI: 1356307516
Provider Name (Legal Business Name): MEHRAK KHADAVI FARAHMAND OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MEHRAK KHADAVI OD

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 UPPER RAGSDALE DR STE B130
MONTEREY CA
93940-7842
US

IV. Provider business mailing address

63 S ROCKFORD DR STE 220
TEMPE AZ
85288-6226
US

V. Phone/Fax

Practice location:
  • Phone: 831-647-3900
  • Fax: 831-771-3966
Mailing address:
  • Phone: 831-647-3900
  • Fax: 831-771-3966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: