Provider Demographics
NPI:1922287648
Name:CALLAWAY, MICHAEL NEIL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:NEIL
Last Name:CALLAWAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:M
Other - Middle Name:NEIL
Other - Last Name:CALLAWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:111 US HIGHWAY 80 SE
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2533
Mailing Address - Country:US
Mailing Address - Phone:912-748-3937
Mailing Address - Fax:912-478-6758
Practice Address - Street 1:111 US HIGHWAY 80 SE
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2533
Practice Address - Country:US
Practice Address - Phone:912-748-3937
Practice Address - Fax:912-478-6758
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001267152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCCDBMedicare UPIN