Provider Demographics
NPI:1578681441
Name:GONCALVES, JOSE (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:GONCALVES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1401 JOHNSON FERRY RD
Mailing Address - Street 2:STE 148B
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6499
Mailing Address - Country:US
Mailing Address - Phone:770-804-1684
Mailing Address - Fax:770-804-1679
Practice Address - Street 1:800 MOUNT VERNON HWY NE
Practice Address - Street 2:SUITE 130
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4295
Practice Address - Country:US
Practice Address - Phone:770-804-1684
Practice Address - Fax:770-804-1679
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002068152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMG0985208OtherDEA
GAMG0985208OtherDEA