Provider Demographics
NPI:1861858128
Name:WASTALU, MARGA RITA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARGA
Middle Name:RITA
Last Name:WASTALU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:215 BEECH TREE HOLW
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-8005
Mailing Address - Country:US
Mailing Address - Phone:678-765-2999
Mailing Address - Fax:678-765-7334
Practice Address - Street 1:215 BEECH TREE HOLW
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-8005
Practice Address - Country:US
Practice Address - Phone:678-765-2999
Practice Address - Fax:678-765-7334
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-01
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2291152W00000X
GAOPT002555152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist