Healthcare Provider Details

I. General information

NPI: 1487719274
Provider Name (Legal Business Name): LADAN MOHTADI ROUHANI O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LADAN CHARLENE MOHTADI O.D.

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 WARREN PKWY STE 605
FRISCO TX
75034-4253
US

IV. Provider business mailing address

8380 WARREN PKWY STE 605
FRISCO TX
75034-4253
US

V. Phone/Fax

Practice location:
  • Phone: 972-668-3131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8377T
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12618T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: