MEDICARE: DR. SAMIN PEZESHK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	8342-T	TX
2	152W00000X	Optometrist	18003589A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801024716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMIN PEZESHK O.D.

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4553 N LOOP 1604 W STE 1225
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-1365
Country	:	US
Telephone Number	:	210-251-2372
Fax Number	:	210-251-2231

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2009
Last Update Date	:	09/13/2023

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Directions to “ DR. SAMIN PEZESHK O.D.” Practice Location

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