Provider Demographics
NPI:1124549332
Name:KIOMALL, CARLY JEAN (OD, MPH)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:JEAN
Last Name:KIOMALL
Suffix:
Gender:F
Credentials:OD, MPH
Other - Prefix:DR
Other - First Name:CARLY
Other - Middle Name:JEAN
Other - Last Name:GRONDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5901 PEACHTREE DUNWOODY RD STE A500
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-7162
Mailing Address - Country:US
Mailing Address - Phone:678-781-7373
Mailing Address - Fax:
Practice Address - Street 1:11690 ALPHARETTA HWY
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3805
Practice Address - Country:US
Practice Address - Phone:770-475-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003301152W00000X
NJ27OA00684900152W00000X
NY008634152W00000X
PAOEG003398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty