Provider Demographics
NPI:1235127986
Name:SCHNEIDER, KENNETH G (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:SCHNEIDER
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 1:72 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-1653
Mailing Address - Country:US
Mailing Address - Phone:706-886-2120
Mailing Address - Fax:706-886-2646
Practice Address - Street 1:72 FALLS RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-1653
Practice Address - Country:US
Practice Address - Phone:706-886-2120
Practice Address - Fax:706-886-2646
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA741152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00004562BMedicaid
GA0066145OtherCIGNA
GA202I417677OtherMEDICARE PTAN
GA24288OtherBLUE CROSS BLUE SHEILD
GAU22388Medicare UPIN