Provider Demographics
NPI:1417467044
Name:GEORGIA OPHTHALMOLOGISTS LLC
Entity Type:Organization
Organization Name:GEORGIA OPHTHALMOLOGISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BIGLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-786-1234
Mailing Address - Street 1:PO BOX 2898
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-7898
Mailing Address - Country:US
Mailing Address - Phone:770-786-1234
Mailing Address - Fax:
Practice Address - Street 1:1747 LANGFORD DR
Practice Address - Street 2:BUILDING 400 SUITE 101
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677
Practice Address - Country:US
Practice Address - Phone:706-549-0005
Practice Address - Fax:678-712-6977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002463152W00000X
GAGA063170207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty