Provider Demographics
NPI:1588792303
Name:SHAFA, HALEH (OD)
Entity type:Individual
Prefix:MS
First Name:HALEH
Middle Name:
Last Name:SHAFA
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 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:404-378-2681
Practice Address - Street 1:3650 STEVE REYNOLDS BLVD
Practice Address - Street 2:KAISER PERMANENTE GWINNETT MEDICAL CENTER
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4506
Practice Address - Country:US
Practice Address - Phone:404-289-8777
Practice Address - Fax:404-289-9949
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002259152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA141200948AMedicaid