Provider Demographics
NPI:1578210589
Name:GWINNETT PEDIATRIC & ADULT EYE CENTER
Entity Type:Organization
Organization Name:GWINNETT PEDIATRIC & ADULT EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OD
Authorized Official - Prefix:
Authorized Official - First Name:SHUNDALE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-783-2162
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 1206
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4550
Mailing Address - Country:US
Mailing Address - Phone:770-783-2162
Mailing Address - Fax:
Practice Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 1206
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4550
Practice Address - Country:US
Practice Address - Phone:334-318-0713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty