Provider Demographics
NPI:1356437883
Name:BASHIR, MUMTAZ F (OD)
Entity type:Individual
Prefix:DR
First Name:MUMTAZ
Middle Name:F
Last Name:BASHIR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2964 SILVERMERE LANE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:678-439-1393
Mailing Address - Fax:678-331-5117
Practice Address - Street 1:2014 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2625
Practice Address - Country:US
Practice Address - Phone:678-649-2020
Practice Address - Fax:678-331-5117
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1909152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000919982BMedicaid
GA000919982BMedicaid
41ZCFBXMedicare ID - Type Unspecified