=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114741501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOZDBAR EYECARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2024
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 RANCH ROAD 620 S STE B112
-----------------------------------------------------
City | LAKEWAY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78734-5623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-263-0225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9807 BAYSHORE BND
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78726-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/OWNER
-----------------------------------------------------
Name | DR. SIMA TAJ MOZDBAR
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 512-921-4755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------