Provider Demographics
NPI:1073548426
Name:TASMAN, STUART R (OD)
Entity Type:Individual
Prefix:MR
First Name:STUART
Middle Name:R
Last Name:TASMAN
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 1:1415 WOOTEN LAKE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1350
Mailing Address - Country:US
Mailing Address - Phone:770-424-8101
Mailing Address - Fax:770-874-1187
Practice Address - Street 1:1545 POWERS FERRY RD SE STE 240
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9401
Practice Address - Country:US
Practice Address - Phone:770-952-6412
Practice Address - Fax:678-369-7212
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000921152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000215773AMedicaid
GA000215773AMedicaid
GAGRP4856Medicare ID - Type Unspecified
GAU22578Medicare UPIN