Provider Demographics
NPI:1578546214
Name:KNEZICH, ANDREW GLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:GLEN
Last Name:KNEZICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:90 VILLAGE AT GLYNN PLACE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525
Mailing Address - Country:US
Mailing Address - Phone:912-264-6000
Mailing Address - Fax:912-280-0991
Practice Address - Street 1:1501 NEWCASTLE ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-6806
Practice Address - Country:US
Practice Address - Phone:912-280-0012
Practice Address - Fax:912-280-0991
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582646940OtherNVA
GA209089721AMedicaid
GAPOO149589OtherMEDICARE RAIL ROAD
GAGK22894OtherSPECTERA
GAGA1803OtherEYE MED
GA32774OtherAVESIS
GA6599375OtherGHI
GA41ZCFLBMedicare ID - Type Unspecified
GAGA1803OtherEYE MED