Provider Demographics
NPI:1083855704
Name:OPTOMETRY CLINIC, INC.
Entity Type:Organization
Organization Name:OPTOMETRY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SMITESH
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-507-3937
Mailing Address - Street 1:312 CASCADE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2805
Mailing Address - Country:US
Mailing Address - Phone:706-593-0709
Mailing Address - Fax:706-682-3931
Practice Address - Street 1:9220 MARNE RD
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5515
Practice Address - Country:US
Practice Address - Phone:706-682-3938
Practice Address - Fax:706-682-3931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA OPT1868152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA404896730AMedicaid