Provider Demographics
NPI:1245959683
Name:FANTAHUN, MERON (OD)
Entity type:Individual
Prefix:DR
First Name:MERON
Middle Name:
Last Name:FANTAHUN
Suffix:
Gender:F
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:PO BOX 207173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7173
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:4153 LAWRENCEVILLE HWY NW STE 5
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2854
Practice Address - Country:US
Practice Address - Phone:770-921-4707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist