Provider Demographics
NPI:1033405568
Name:SHAH, LAILA MOUSAVI
Entity Type:Individual
Prefix:DR
First Name:LAILA
Middle Name:MOUSAVI
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22542 SWANSTONE CT
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-9022
Mailing Address - Country:US
Mailing Address - Phone:858-472-6162
Mailing Address - Fax:
Practice Address - Street 1:2435 COMMERCE AVE BLDG 2200
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4980
Practice Address - Country:US
Practice Address - Phone:858-472-6162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14151152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist