Provider Demographics
NPI:1376539445
Name:AHLMARK-GORDON, RENEE CANDACE (OD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:CANDACE
Last Name:AHLMARK-GORDON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1569 US HIGHWAY 19 S
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-4939
Mailing Address - Country:US
Mailing Address - Phone:229-439-1200
Mailing Address - Fax:229-255-2929
Practice Address - Street 1:1569 US HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-4939
Practice Address - Country:US
Practice Address - Phone:229-439-1200
Practice Address - Fax:229-255-2929
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003105037AMedicaid
GA41ZCFLSMedicare ID - Type Unspecified