Provider Demographics
NPI:1871145672
Name:JIVRAJ, FAREEM (OD)
Entity type:Individual
Prefix:DR
First Name:FAREEM
Middle Name:
Last Name:JIVRAJ
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 1:3394 BRYERSTONE CIR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-4810
Mailing Address - Country:US
Mailing Address - Phone:857-269-6286
Mailing Address - Fax:
Practice Address - Street 1:3393 PEACHTREE RD NE STE B128
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1197
Practice Address - Country:US
Practice Address - Phone:857-269-6286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003170152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist