Provider Demographics
NPI:1780677476
Name:ZADEH, MAURICE EBRAHIM (OD)
Entity Type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:EBRAHIM
Last Name:ZADEH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 HOLCOMB BRIDGE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1975
Mailing Address - Country:US
Mailing Address - Phone:770-992-6789
Mailing Address - Fax:770-664-6789
Practice Address - Street 1:910 HOLCOMB BRIDGE RD
Practice Address - Street 2:STE 100
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1975
Practice Address - Country:US
Practice Address - Phone:770-992-6789
Practice Address - Fax:770-640-6789
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA001234152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000641319AMedicaid
GAU11762Medicare UPIN
GA000641319AMedicaid