Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 13893 | CA |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 13893 | CA |
N | 152WP0200X | Pediatric Optomitrist | 13893 | CA |
N | 152WV0400X | Optomitrist - Vision Therapist | 13893 | CA |
N | 152WX0102X | Occupational Vision | 13893 | CA |
NPI | 1013247212 |
---|---|
Provider Name | Dr. Angela Khakshooy |
First Address | San Dimas, CA 91773-2543 |
Second Address | Henderson, NV 89052-3844 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2010 |
Last Update Date | 01/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC965Z | (02) | CA |