Provider Demographics
NPI:1104352806
Name:NIKKI IRAVANI OD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:NIKKI IRAVANI OD A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NIKOO
Authorized Official - Middle Name:
Authorized Official - Last Name:IRAVANI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-528-7100
Mailing Address - Street 1:2702 AUGUSTINE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-2940
Mailing Address - Country:US
Mailing Address - Phone:408-528-7100
Mailing Address - Fax:
Practice Address - Street 1:2702 AUGUSTINE DR STE 120
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054-2940
Practice Address - Country:US
Practice Address - Phone:408-528-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9985T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659803088OtherNPI 1
CA13920487OtherCAQH