Provider Demographics
NPI:1073688115
Name:OXLEY, LYN BROWN (OD)
Entity Type:Individual
Prefix:
First Name:LYN
Middle Name:BROWN
Last Name:OXLEY
Suffix:
Gender:F
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: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 1:104 ANDREW ST STE 112
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7241
Practice Address - Country:US
Practice Address - Phone:912-537-4447
Practice Address - Fax:912-537-2743
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001073152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0003442801BMedicaid
SC0126380001Medicare ID - Type UnspecifiedPALMETTO MEDICARE
GAU22707Medicare UPIN