Healthcare Provider Details

I. General information

NPI: 1811545965
Provider Name (Legal Business Name): HIRA NAWAL FATIMA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2019
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 LOGANVILLE HWY
BETHLEHEM GA
30620-2144
US

IV. Provider business mailing address

3920 LAKE BURTON DR
DULUTH GA
30097-7928
US

V. Phone/Fax

Practice location:
  • Phone: 504-222-5412
  • Fax:
Mailing address:
  • Phone: 504-222-5412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003216
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT006741
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: