Healthcare Provider Details

I. General information

NPI: 1336191899
Provider Name (Legal Business Name): LOPA SHETH O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 FURYS FERRY RD
MARTINEZ GA
30907-9059
US

IV. Provider business mailing address

1950 OLD GALLOWS RD SUITE 520
VIENNA VA
22182-3990
US

V. Phone/Fax

Practice location:
  • Phone: 706-860-8899
  • Fax: 706-863-7822
Mailing address:
  • Phone: 703-847-8899
  • Fax: 703-991-0514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001520
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: