Provider Demographics
NPI:1780654483
Name:EYE TO EYE VISION CENTER
Entity Type:Organization
Organization Name:EYE TO EYE VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:JERUSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-578-1900
Mailing Address - Street 1:2255 SEWELL MILL RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-2804
Mailing Address - Country:US
Mailing Address - Phone:770-578-1900
Mailing Address - Fax:770-578-6623
Practice Address - Street 1:2255 SEWELL MILL RD
Practice Address - Street 2:SUITE 310
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-2804
Practice Address - Country:US
Practice Address - Phone:770-578-1900
Practice Address - Fax:770-578-6623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1332-T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4182Medicare PIN
GAT-93916Medicare UPIN