Provider Demographics
NPI:1669491437
Name:THURMOND, STEPHEN R (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:THURMOND
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:PO BOX 2105
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0053
Mailing Address - Country:US
Mailing Address - Phone:706-782-3535
Mailing Address - Fax:706-782-7525
Practice Address - Street 1:50 EARL ST
Practice Address - Street 2:SUITE A
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-782-3535
Practice Address - Fax:706-782-7525
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001354152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52403378OtherBLUECROSS BLUESHIELD
GA00521562AMedicaid
GA0567940001Medicare NSC
GA41ZCCDQMedicare Oscar/Certification
GA52403378OtherBLUECROSS BLUESHIELD