Healthcare Provider Details

I. General information

NPI: 1154486090
Provider Name (Legal Business Name): KAYGOSHTASB KAVOUSI OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 12 NORTH RIVERSIDE MALL, PEARLE VISION
UTICA NY
13502
US

IV. Provider business mailing address

PO BOX 363
LAKEWOOD NY
14750-0363
US

V. Phone/Fax

Practice location:
  • Phone: 315-000-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007112-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001619
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOET009046
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number02380
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2566
License Number StateCO
# 6
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100127
License Number StateID
# 7
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number63558749934
License Number StateUT
# 8
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD-619
License Number StateHI
# 9
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00003937
License Number StateWA
# 10
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT12719-TPA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: