Provider Demographics
NPI:1861507261
Name:PROVOST EYE GROUP, P.C.
Entity Type:Organization
Organization Name:PROVOST EYE GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:ALEX
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-431-1713
Mailing Address - Street 1:2900 CUMBERLAND MALL SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339
Mailing Address - Country:US
Mailing Address - Phone:770-431-1713
Mailing Address - Fax:770-431-1714
Practice Address - Street 1:2900 CUMBERLAND MALL SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339
Practice Address - Country:US
Practice Address - Phone:770-431-1713
Practice Address - Fax:770-431-1714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty