Provider Demographics
NPI:1174579577
Name:BAHMANYAR, SINA (MD)
Entity type:Individual
Prefix:
First Name:SINA
Middle Name:
Last Name:BAHMANYAR
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 1:6785 WEAVER RD
Mailing Address - Street 2:STE D
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8055
Mailing Address - Country:US
Mailing Address - Phone:815-395-1157
Mailing Address - Fax:
Practice Address - Street 1:1075 FEATHERSTONE RD
Practice Address - Street 2:STE 10
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5906
Practice Address - Country:US
Practice Address - Phone:815-395-1157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E38585Medicare UPIN