Provider Demographics
NPI:1609513910
Name:TOLBERT, GREG
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:TOLBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 SHORTER AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2018
Mailing Address - Country:US
Mailing Address - Phone:706-291-7842
Mailing Address - Fax:
Practice Address - Street 1:2110 SHORTER AVE NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2018
Practice Address - Country:US
Practice Address - Phone:706-291-7842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO001046156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician