Provider Demographics
NPI:1639300502
Name:JOSE GONCALVES PC
Entity Type:Organization
Organization Name:JOSE GONCALVES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONCALVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-906-3030
Mailing Address - Street 1:1061 FIELDSTONE TRAIL
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004
Mailing Address - Country:US
Mailing Address - Phone:770-906-3030
Mailing Address - Fax:
Practice Address - Street 1:1401 JOHNSON FERRY RD SUITE 148B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:770-509-8480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAT002068152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty