Provider Demographics
NPI:1851344881
Name:J ELLIS COSBY OD PC
Entity Type:Organization
Organization Name:J ELLIS COSBY OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:COSBY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:229-435-7795
Mailing Address - Street 1:2616 POINTE NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-1526
Mailing Address - Country:US
Mailing Address - Phone:229-435-7795
Mailing Address - Fax:
Practice Address - Street 1:2616 POINTE NORTH BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-1526
Practice Address - Country:US
Practice Address - Phone:229-435-7795
Practice Address - Fax:229-883-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1852152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0616090001Medicare NSC
GAU81543Medicare UPIN
GAGRP3784Medicare PIN