=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942681754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAHAR MAHZOON DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2015
-----------------------------------------------------
Last Update Date | 03/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 COOK ST
-----------------------------------------------------
City | ROYSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30662-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 762-444-6035
-----------------------------------------------------
Fax | 762-444-6738
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 COOK ST
-----------------------------------------------------
City | ROYSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30662-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 762-444-6035
-----------------------------------------------------
Fax | 762-444-6738
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | POD001401
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------