Provider Demographics
NPI:1053489104
Name:POPHAM, B. E JR (OD)
Entity Type:Individual
Prefix:DR
First Name:B.
Middle Name:E
Last Name:POPHAM
Suffix:JR
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 1:12 NELSON ST
Mailing Address - Street 2:P. O. BOX 295
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2813
Mailing Address - Country:US
Mailing Address - Phone:770-382-1144
Mailing Address - Fax:770-382-1144
Practice Address - Street 1:12 NELSON ST
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2813
Practice Address - Country:US
Practice Address - Phone:770-382-1144
Practice Address - Fax:770-382-1144
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA669-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00112626AMedicaid
GAU22376Medicare UPIN
GA00112626AMedicaid