Provider Demographics
NPI:1528228616
Name:STONE MOUNTAIN EYE CENTER
Entity Type:Organization
Organization Name:STONE MOUNTAIN EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SOBANJO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-498-3434
Mailing Address - Street 1:1525 E PARK PLACE BLVD STE 1800
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6403
Mailing Address - Country:US
Mailing Address - Phone:770-498-3434
Mailing Address - Fax:770-498-3440
Practice Address - Street 1:1525 E PARK PLACE BLVD STE 1800
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-6403
Practice Address - Country:US
Practice Address - Phone:770-498-3434
Practice Address - Fax:770-498-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1538261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0009004134Medicaid
GA202G-703-432Medicare PIN