Provider Demographics
NPI:1568152320
Name:ATHEARN, BRIAN (LDO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:ATHEARN
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5451
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30916-5451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4471 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-6351
Practice Address - Country:US
Practice Address - Phone:706-854-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1338156FX1800X
SC657156FX1800X
GALDO002929156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician