=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154640712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANTA ATAROD-ZADEH, O.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2010
-----------------------------------------------------
Last Update Date | 05/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3542 CORAL WAY
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33145-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-441-0533
-----------------------------------------------------
Fax | 305-441-0543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3542 CORAL WAY
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33145-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-441-0533
-----------------------------------------------------
Fax | 305-441-0543
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PANTA ATAROD-ZADEH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 305-441-0533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC3659
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------