Healthcare Provider Details

I. General information

NPI: 1942565890
Provider Name (Legal Business Name): MITHAQ VAHEDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 CRAIG RD
EAU CLAIRE WI
54701-6149
US

IV. Provider business mailing address

2116 CRAIG RD
EAU CLAIRE WI
54701-6149
US

V. Phone/Fax

Practice location:
  • Phone: 715-858-4770
  • Fax: 715-858-4509
Mailing address:
  • Phone: 715-858-4770
  • Fax: 715-858-4509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301100583
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number83403
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2022006661
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number8340320
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10086196
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number83403
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number277593
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301100583
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: