Healthcare Provider Details

I. General information

NPI: 1679317226
Provider Name (Legal Business Name): ATHAR SHADMANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4407 CARLISLE PIKE
CAMP HILL PA
17011-4159
US

IV. Provider business mailing address

2661 RIVA RD STE 1030
ANNAPOLIS MD
21401-7131
US

V. Phone/Fax

Practice location:
  • Phone: 717-975-2015
  • Fax:
Mailing address:
  • Phone: 570-288-7405
  • Fax: 570-288-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD491655
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN39136
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: