Provider Demographics
NPI:1457445116
Name:FLEETWOOD, JR., JOHN TRAFTON (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TRAFTON
Last Name:FLEETWOOD, JR.
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 1:244 E 64TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5305
Mailing Address - Country:US
Mailing Address - Phone:912-691-0459
Mailing Address - Fax:912-355-1886
Practice Address - Street 1:SAVANNAH MALL
Practice Address - Street 2:7400 ABERCORN STE 807-809
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1957
Practice Address - Country:US
Practice Address - Phone:912-352-0600
Practice Address - Fax:912-355-1886
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000929152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCCVMMedicare ID - Type Unspecified
GAU22283Medicare UPIN