Provider Demographics
NPI:1629276464
Name:GINA R DURANT
Entity Type:Organization
Organization Name:GINA R DURANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:DURANT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:478-625-7605
Mailing Address - Street 1:144 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30434-1620
Mailing Address - Country:US
Mailing Address - Phone:478-625-7605
Mailing Address - Fax:478-625-7605
Practice Address - Street 1:144 E BROAD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:GA
Practice Address - Zip Code:30434-1620
Practice Address - Country:US
Practice Address - Phone:478-625-7605
Practice Address - Fax:478-625-7605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1272-T152W00000X
GA1273-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000479674BMedicaid
GA00515193BMedicaid
GA00515193BMedicaid
GA41ZCCHNMedicare ID - Type Unspecified
GAGRP1624Medicare PIN
GAU25482Medicare UPIN
GAU28357Medicare UPIN