Provider Demographics
NPI:1932322302
Name:ETOWAH EYE CLINIC, P.C.
Entity Type:Organization
Organization Name:ETOWAH EYE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PARKER
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:678-880-0662
Mailing Address - Street 1:125 OAKSIDE CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2498
Mailing Address - Country:US
Mailing Address - Phone:678-880-0662
Mailing Address - Fax:678-880-0675
Practice Address - Street 1:125 OAKSIDE CT
Practice Address - Street 2:SUITE 102
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2498
Practice Address - Country:US
Practice Address - Phone:678-880-0662
Practice Address - Fax:678-880-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030829207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4771660001Medicare NSC
GAE84469Medicare UPIN
GAGRP4786Medicare ID - Type UnspecifiedGROUP NUMBER