Provider Demographics
NPI:1356478077
Name:GEORGIA OPHTHALMOLOGY ASSOC PC
Entity Type:Organization
Organization Name:GEORGIA OPHTHALMOLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:P
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-298-5557
Mailing Address - Street 1:465 WINN WAY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1753
Mailing Address - Country:US
Mailing Address - Phone:404-298-5557
Mailing Address - Fax:404-297-9480
Practice Address - Street 1:465 WINN WAY
Practice Address - Street 2:SUITE 140
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1753
Practice Address - Country:US
Practice Address - Phone:404-298-5557
Practice Address - Fax:404-297-9480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017845207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2817OtherMEDICARE - GROUP