Provider Demographics
NPI:1972836013
Name:DISTINCTIVE EYE CARE PC
Entity Type:Organization
Organization Name:DISTINCTIVE EYE CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:JAIKARAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:678-691-0073
Mailing Address - Street 1:6750 JAMESTOWN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-3030
Mailing Address - Country:US
Mailing Address - Phone:678-691-0073
Mailing Address - Fax:888-707-4495
Practice Address - Street 1:6750 JAMESTOWN DRIVE
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3030
Practice Address - Country:US
Practice Address - Phone:678-691-0073
Practice Address - Fax:888-707-4495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002111152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G418690Medicare PIN
6378850001Medicare NSC