Provider Demographics
NPI:1760870612
Name:TERRELL, MICHAEL (LDO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:TERRELL
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 CAMBRIDGE CREEK DR SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5081
Mailing Address - Country:US
Mailing Address - Phone:404-933-9450
Mailing Address - Fax:
Practice Address - Street 1:806 CAMBRIDGE CREEK DR
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094
Practice Address - Country:US
Practice Address - Phone:404-933-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002484156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician