Provider Demographics
NPI:1588659692
Name:GURBAL, NICOLE A (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:A
Last Name:GURBAL
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 1:619 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3816
Mailing Address - Country:US
Mailing Address - Phone:770-834-0212
Mailing Address - Fax:770-834-0213
Practice Address - Street 1:619 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3816
Practice Address - Country:US
Practice Address - Phone:770-834-0212
Practice Address - Fax:770-834-0213
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002230152W00000X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAV02039Medicare UPIN
GA41ZCGBFMedicare PIN