Provider Demographics
NPI:1588211460
Name:KOROTANA, PAVENDEEP (OD)
Entity Type:Individual
Prefix:
First Name:PAVENDEEP
Middle Name:
Last Name:KOROTANA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 PROFESSIONAL PKWY STE 2000
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5632
Mailing Address - Country:US
Mailing Address - Phone:770-949-3885
Mailing Address - Fax:
Practice Address - Street 1:800 MOUNT VERNON HWY NE STE 130
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-4293
Practice Address - Country:US
Practice Address - Phone:770-255-1249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-24
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003173152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist