Healthcare Provider Details

I. General information

NPI: 1780677476
Provider Name (Legal Business Name): MAURICE EBRAHIM ZADEH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 HOLCOMB BRIDGE RD STE 100
ROSWELL GA
30076-1975
US

IV. Provider business mailing address

910 HOLCOMB BRIDGE RD STE 100
ROSWELL GA
30076-1975
US

V. Phone/Fax

Practice location:
  • Phone: 770-992-6789
  • Fax: 770-640-6789
Mailing address:
  • Phone: 770-992-6789
  • Fax: 770-664-6789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberGA001234
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: