Provider Demographics
NPI:1073730263
Name:DEPOE EYE CENTER PC
Entity Type:Organization
Organization Name:DEPOE EYE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNDER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEPOE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-474-1237
Mailing Address - Street 1:550 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 208
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9081
Mailing Address - Country:US
Mailing Address - Phone:770-474-1237
Mailing Address - Fax:
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3296
Practice Address - Country:US
Practice Address - Phone:770-603-0063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001305152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000493149BMedicaid
GA90932Medicaid
GA000493149AMedicaid
GA90932Medicaid
GA4967530001Medicare ID - Type UnspecifiedMC SUPPLY
GAU29630Medicare UPIN
GA000493149AMedicaid