MEDICARE: DR. LAILA MOUSAVI SHAH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	14151	CA

General Provider Information

NPI Number	:	1033405568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAILA MOUSAVI SHAH

Provider Business Mailing Address
First Line	:	22542 SWANSTONE CT
Second Line	:
City	:	FRANKFORT
State	:	IL
Zip	:	60423-9022
Country	:	US
Telephone Number	:	858-472-6162
Fax Number	:

Provider Business Practice Location Address
First Line	:	2435 COMMERCE AVE BLDG 2200
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-4980
Country	:	US
Telephone Number	:	858-472-6162
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	04/03/2023

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