Provider Demographics
NPI:1487974853
Name:MEHDI KAZEMZADEH, OPTOMETRIST, P C
Entity type:Organization
Organization Name:MEHDI KAZEMZADEH, OPTOMETRIST, P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZEMZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:678-993-2020
Mailing Address - Street 1:575 PROFESSIONAL DR
Mailing Address - Street 2:100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3333
Mailing Address - Country:US
Mailing Address - Phone:678-993-2020
Mailing Address - Fax:678-993-2000
Practice Address - Street 1:575 PROFESSIONAL DR
Practice Address - Street 2:100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3333
Practice Address - Country:US
Practice Address - Phone:678-993-2020
Practice Address - Fax:678-993-2000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000824865BMedicaid
GA41ZCCZWMedicare Oscar/Certification
GAU56179Medicare UPIN
GA000824865BMedicaid