Healthcare Provider Details

I. General information

NPI: 1770907966
Provider Name (Legal Business Name): KIARASH BASSIRI, OD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 CREEDMOOR RD SUITE 103
RALEIGH NC
27613-3600
US

IV. Provider business mailing address

6400 CREEDMOOR RD STE 103
RALEIGH NC
27613-4482
US

V. Phone/Fax

Practice location:
  • Phone: 919-977-7480
  • Fax: 919-977-7481
Mailing address:
  • Phone: 919-977-7480
  • Fax: 919-977-7481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2055
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2055
License Number StateNC

VIII. Authorized Official

Name: DR. KIARASH BASSIRI
Title or Position: PRESIDENT
Credential: OD
Phone: 919-977-7480