Healthcare Provider Details

I. General information

NPI: 1306921101
Provider Name (Legal Business Name): MEHDI KAZEMZADEH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 PROFESSIONAL DR SUITE 100
LAWRENCEVILLE GA
30046-3333
US

IV. Provider business mailing address

575 PROFESSIONAL DR STE 100
LAWRENCEVILLE GA
30046-3300
US

V. Phone/Fax

Practice location:
  • Phone: 678-993-2020
  • Fax:
Mailing address:
  • Phone: 770-822-9747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT001423
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: