Healthcare Provider Details

I. General information

NPI: 1891360111
Provider Name (Legal Business Name): FAWAD ZADRAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 HIGHWAY 49
SAN ANDREAS CA
95249
US

IV. Provider business mailing address

1089 CRESTLINE CIR
EL DORADO HILLS CA
95762-7224
US

V. Phone/Fax

Practice location:
  • Phone: 209-755-1480
  • Fax: 209-674-6190
Mailing address:
  • Phone: 916-850-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: