Provider Demographics
NPI:1619982485
Name:COURTENAY, CLIFFORD D (OD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:D
Last Name:COURTENAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1711
Mailing Address - Country:US
Mailing Address - Phone:229-247-4114
Mailing Address - Fax:229-245-9042
Practice Address - Street 1:3024 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1711
Practice Address - Country:US
Practice Address - Phone:229-247-4114
Practice Address - Fax:229-245-9042
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT00145152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000317138BMedicaid
GA41CBVNMedicare ID - Type Unspecified
GA000317138BMedicaid