Provider Demographics
NPI:1043385172
Name:OPTOMETRY ASSOCIATES, PC
Entity Type:Organization
Organization Name:OPTOMETRY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYN
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:OXLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:912-537-4447
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0406
Mailing Address - Country:US
Mailing Address - Phone:912-537-4447
Mailing Address - Fax:912-537-2743
Practice Address - Street 1:300 DURDEN ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4606
Practice Address - Country:US
Practice Address - Phone:912-537-4447
Practice Address - Fax:912-537-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001073152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0126380001Medicare ID - Type UnspecifiedPALMETTO MEDICARE
GAGRP1630Medicare ID - Type Unspecified
GAU22707Medicare UPIN