Provider Demographics
NPI:1376737486
Name:COWART, DENNIS LEE (OD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:LEE
Last Name:COWART
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:207 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2021
Practice Address - Country:US
Practice Address - Phone:770-537-5246
Practice Address - Fax:770-537-1313
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA009915685OtherALABAMA MEDICAID
GA000204256AMedicaid
GA000204256AMedicaid