Provider Demographics
NPI:1518084961
Name:KLEINMAN, EDWARD T (LDO)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:T
Last Name:KLEINMAN
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:EYE
Other - Middle Name:
Other - Last Name:OPTIQUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10800 ALPHARETTA HWY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1490
Mailing Address - Country:US
Mailing Address - Phone:770-642-7720
Mailing Address - Fax:770-642-6651
Practice Address - Street 1:10800 ALPHARETTA HWY
Practice Address - Street 2:SUITE 220
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1490
Practice Address - Country:US
Practice Address - Phone:770-642-7720
Practice Address - Fax:770-642-6651
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0604156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA0604OtherEYEMED PROVIDER
GA07526OtherSPECTERA PROVIDER
GA14193OtherAVESIS PIN
GA40968OtherDAVIS VISION PROVIDER NUM