Provider Demographics
NPI:1558120287
Name:ABDULHAFIZ, OMAR (LDO)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ABDULHAFIZ
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 WELLSTONE PL
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-7077
Mailing Address - Country:US
Mailing Address - Phone:512-806-5360
Mailing Address - Fax:
Practice Address - Street 1:10300 INDUSTRIAL BLVD NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1477
Practice Address - Country:US
Practice Address - Phone:770-788-7732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002981156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician