Provider Demographics
NPI:1194954677
Name:ELIASIEH, KASRA (MD)
Entity type:Individual
Prefix:
First Name:KASRA
Middle Name:
Last Name:ELIASIEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 TELEGRAPH AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2049
Mailing Address - Country:US
Mailing Address - Phone:510-899-7466
Mailing Address - Fax:510-899-6024
Practice Address - Street 1:3017 TELEGRAPH AVE STE 210
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2049
Practice Address - Country:US
Practice Address - Phone:510-899-7466
Practice Address - Fax:510-899-6024
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132513207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD055392100Medicaid
MD055392100Medicaid