Provider Demographics
NPI:1477638849
Name:W WAYNE WEST OD PC
Entity Type:Organization
Organization Name:W WAYNE WEST OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:GOODSON
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-783-4186
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-0446
Mailing Address - Country:US
Mailing Address - Phone:478-783-4186
Mailing Address - Fax:478-783-4185
Practice Address - Street 1:545 COMMERCE STREET
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-1139
Practice Address - Country:US
Practice Address - Phone:478-783-4186
Practice Address - Fax:478-783-4185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0PT000682152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100752OtherAVESIS
GA000004936A4Medicaid
GA0599260001Medicare NSC
GA000004936A4Medicaid
T86454Medicare UPIN