Provider Demographics
NPI:1639511223
Name:KOTEI, CANDACE HINES (OD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:HINES
Last Name:KOTEI
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 1:180 JACKSON ST NE
Mailing Address - Street 2:APT 6115
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1303
Mailing Address - Country:US
Mailing Address - Phone:260-241-5617
Mailing Address - Fax:
Practice Address - Street 1:4280 E WEST CONNECTOR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4804
Practice Address - Country:US
Practice Address - Phone:770-435-4457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002774152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist