Provider Demographics
NPI:1659308872
Name:BLUE LASER GROUP
Entity Type:Organization
Organization Name:BLUE LASER GROUP
Other - Org Name:BLUE LASER GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTHALMOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-549-0005
Mailing Address - Street 1:1747 LANGFORD DRIVE
Mailing Address - Street 2:BUILDING 400, SUITE 101
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622
Mailing Address - Country:US
Mailing Address - Phone:706-549-0005
Mailing Address - Fax:706-850-3180
Practice Address - Street 1:1747 LANGFORD DRIVE
Practice Address - Street 2:BUILDING 400, SUITE 101
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622
Practice Address - Country:US
Practice Address - Phone:706-549-0005
Practice Address - Fax:706-850-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027348207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA027348OtherGA LICENCE
GA00301793AMedicaid
GAAB1189186OtherDEA
NCBB9148479OtherDEA
NCBB9148479OtherDEA
GA027348OtherGA LICENCE
GAAB1189186OtherDEA