Provider Demographics
NPI:1942565890
Name:VAHEDI, MITHAQ (MD)
Entity type:Individual
Prefix:DR
First Name:MITHAQ
Middle Name:
Last Name:VAHEDI
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 1:2116 CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6149
Mailing Address - Country:US
Mailing Address - Phone:715-858-4770
Mailing Address - Fax:715-858-4509
Practice Address - Street 1:2116 CRAIG RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6149
Practice Address - Country:US
Practice Address - Phone:715-858-4770
Practice Address - Fax:715-858-4509
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100583207W00000X, 207P00000X
WI83403207P00000X, 207W00000X
MO2022006661207W00000X
WI8340320207WX0009X
TXBP10086196390200000X
NY277593207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200112086Medicaid