Provider Demographics
NPI:1306921101
Name:KAZEMZADEH, MEHDI (OD)
Entity type:Individual
Prefix:
First Name:MEHDI
Middle Name:
Last Name:KAZEMZADEH
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 1:575 PROFESSIONAL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3300
Mailing Address - Country:US
Mailing Address - Phone:770-822-9747
Mailing Address - Fax:
Practice Address - Street 1:575 PROFESSIONAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3333
Practice Address - Country:US
Practice Address - Phone:678-993-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001423152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000824865BMedicaid
U56179Medicare UPIN
GA41ZCCZWMedicare Oscar/Certification
GA202G706890Medicare PIN