Provider Demographics
NPI:1376613968
Name:HART-MORELAND, SANTRELL DENISE (OD,MPH)
Entity Type:Individual
Prefix:DR
First Name:SANTRELL
Middle Name:DENISE
Last Name:HART-MORELAND
Suffix:
Gender:F
Credentials:OD,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 FAIRVIEW RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2795
Mailing Address - Country:US
Mailing Address - Phone:678-289-5835
Mailing Address - Fax:678-289-5837
Practice Address - Street 1:158 FAIRVIEW RD
Practice Address - Street 2:SUITE B
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2795
Practice Address - Country:US
Practice Address - Phone:678-289-5835
Practice Address - Fax:678-289-5837
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001761152W00000X, 152WC0802X, 152WP0200X
GA1761133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00832818BMedicaid
GA00832818CMedicaid
GA00832818BMedicaid
GA41ZCDQWMedicare ID - Type Unspecified