Provider Demographics
NPI:1417404690
Name:BAGHDADY, REHAM ADEL (OD)
Entity type:Individual
Prefix:
First Name:REHAM
Middle Name:ADEL
Last Name:BAGHDADY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 E 125TH PL
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7546
Mailing Address - Country:US
Mailing Address - Phone:219-789-9429
Mailing Address - Fax:
Practice Address - Street 1:279 W 80TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5491
Practice Address - Country:US
Practice Address - Phone:219-738-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004011152W00000X
MI4901005012152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18004011OtherLICENSE