Healthcare Provider Details

I. General information

NPI: 1235164377
Provider Name (Legal Business Name): SAMIA IDRIS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 PLEASANT HILL RD H10-1
DULUTH GA
30096-4701
US

IV. Provider business mailing address

11103 WEST AVE 6
SAN ANTONIO TX
78213-1370
US

V. Phone/Fax

Practice location:
  • Phone: 678-475-0500
  • Fax: 678-475-0563
Mailing address:
  • Phone: 210-524-6663
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001870
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: