Provider Demographics
NPI:1164555942
Name:POTTLITZER, EDWARD HERMAN (OD)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:HERMAN
Last Name:POTTLITZER
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 1:2911 CHAPEL HILL RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135
Mailing Address - Country:US
Mailing Address - Phone:770-949-4223
Mailing Address - Fax:770-949-4994
Practice Address - Street 1:2911 CHAPEL HILL RD
Practice Address - Street 2:SUITE 210
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135
Practice Address - Country:US
Practice Address - Phone:770-949-4223
Practice Address - Fax:770-949-4994
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA79949Medicaid
GA79949Medicaid