Healthcare Provider Details

I. General information

NPI: 1235293499
Provider Name (Legal Business Name): MATHEW BAHRAMI OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 WALDORF MARKET PL
WALDORF MD
20603-4872
US

IV. Provider business mailing address

3080 WALDORF MARKET PL
WALDORF MD
20603-4872
US

V. Phone/Fax

Practice location:
  • Phone: 301-843-9112
  • Fax: 301-843-9989
Mailing address:
  • Phone: 301-843-9112
  • Fax: 301-843-9989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA3175
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD1816
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-2025-0013
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: