Provider Demographics
NPI:1962461319
Name:TITAK, JOHN E (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:TITAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1421
Mailing Address - Country:US
Mailing Address - Phone:678-432-3144
Mailing Address - Fax:678-432-3420
Practice Address - Street 1:3 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:AVONDALE ESTATES
Practice Address - State:GA
Practice Address - Zip Code:30002-1421
Practice Address - Country:US
Practice Address - Phone:678-432-3144
Practice Address - Fax:678-432-3420
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000743597NMedicaid
GA41ZCDWDMedicare ID - Type Unspecified
GAU53441Medicare UPIN