Provider Demographics
NPI:1528841210
Name:KHATAMI, MARYAM (OD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:KHATAMI
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 1:4521 CAMPUS DR # 531
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2621
Mailing Address - Country:US
Mailing Address - Phone:818-748-7554
Mailing Address - Fax:
Practice Address - Street 1:1893 W MALVERN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-2403
Practice Address - Country:US
Practice Address - Phone:714-278-9065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist