Provider Demographics
NPI:1033264510
Name:JABALEY, RICHARD GERARD (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GERARD
Last Name:JABALEY
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 1:431 GROVE ST N
Mailing Address - Street 2:SUITE C
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0436
Mailing Address - Country:US
Mailing Address - Phone:706-864-8635
Mailing Address - Fax:706-864-2441
Practice Address - Street 1:431 GROVE ST N
Practice Address - Street 2:SUITE C
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-0436
Practice Address - Country:US
Practice Address - Phone:706-864-8635
Practice Address - Fax:706-864-2441
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1389152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00712269AMedicaid
GAU44974Medicare UPIN
GA00712269AMedicaid