Provider Demographics
NPI:1528127578
Name:MORTAZAVI, ANOUSHEH (OD)
Entity type:Individual
Prefix:DR
First Name:ANOUSHEH
Middle Name:
Last Name:MORTAZAVI
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 1:2300 HILLTOP MALL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1926
Mailing Address - Country:US
Mailing Address - Phone:510-222-3809
Mailing Address - Fax:413-581-7905
Practice Address - Street 1:2300 HILLTOP MALL RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-1926
Practice Address - Country:US
Practice Address - Phone:510-222-3809
Practice Address - Fax:413-581-7905
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9564152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U20573Medicare UPIN