Provider Demographics
NPI:1679199582
Name:GHANIPOUR, AMIR (OD)
Entity Type:Individual
Prefix:DR
First Name:AMIR
Middle Name:
Last Name:GHANIPOUR
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 1:1100 JOHNSON FY RD NE STE 108
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1733
Mailing Address - Country:US
Mailing Address - Phone:404-531-9988
Mailing Address - Fax:
Practice Address - Street 1:1100 JOHNSON FY RD NE STE 108
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1733
Practice Address - Country:US
Practice Address - Phone:404-531-9988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty