=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295622298
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONICA GHIMIRE OPTOMETRIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2025
-----------------------------------------------------
Last Update Date | 06/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4153 LAVISTA RD STE C
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-5344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-939-8828
-----------------------------------------------------
Fax | 770-939-3966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4026 LONGLEAF LN
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-6515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-469-5988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT003667
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------