Provider Demographics
NPI:1083095863
Name:MOTAMEDI, SHAHAB (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAHAB
Middle Name:
Last Name:MOTAMEDI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3134 CRAIN HWY
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4846
Mailing Address - Country:US
Mailing Address - Phone:610-349-6810
Mailing Address - Fax:
Practice Address - Street 1:3134 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4846
Practice Address - Country:US
Practice Address - Phone:610-349-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist