Healthcare Provider Details

I. General information

NPI: 1952411969
Provider Name (Legal Business Name): NADIRA SOAD SHADEED O.D., F.C.O.V.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 HAMILTON CREEK PKWY STE 120
DACULA GA
30019-7205
US

IV. Provider business mailing address

3518 HABERSHAM CLUB DR
CUMMING GA
30041-8003
US

V. Phone/Fax

Practice location:
  • Phone: 770-904-0979
  • Fax:
Mailing address:
  • Phone: 678-448-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2355
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1440
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1440
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2355
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: