Healthcare Provider Details

I. General information

NPI: 1013247212
Provider Name (Legal Business Name): ANGELA KHAKSHOOY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2010
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 E LAKE MEAD PKWY
HENDERSON NV
89015-5531
US

IV. Provider business mailing address

61 E LAKE MEAD PKWY
HENDERSON NV
89015-5531
US

V. Phone/Fax

Practice location:
  • Phone: 702-565-7579
  • Fax:
Mailing address:
  • Phone: 702-565-7579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number13893
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number13893
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number13893
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number13893
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: