Provider Demographics
NPI:1972734226
Name:SCOTT EYE CLINIC
Entity Type:Organization
Organization Name:SCOTT EYE CLINIC
Other - Org Name:SCOTT EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WILKIN
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:770-445-9866
Mailing Address - Street 1:4075 MARIETTA HWY STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-3317
Mailing Address - Country:US
Mailing Address - Phone:770-445-9866
Mailing Address - Fax:770-445-8244
Practice Address - Street 1:4075 MARIETTA HWY STE 110
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-3317
Practice Address - Country:US
Practice Address - Phone:770-445-9866
Practice Address - Fax:770-445-8244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1253261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0988940001Medicare NSC