Healthcare Provider Details

I. General information

NPI: 1508431255
Provider Name (Legal Business Name): POOJA SHAILESH PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10775 ALPHARETTA HWY
ROSWELL GA
30076-1772
US

IV. Provider business mailing address

316 S HAMILTON RD
GAHANNA OH
43230-3350
US

V. Phone/Fax

Practice location:
  • Phone: 770-998-9656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003357
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: