Provider Demographics
NPI:1982831756
Name:MODERN EYES OF GEORGIA, LLC
Entity Type:Organization
Organization Name:MODERN EYES OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DUDOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-831-1010
Mailing Address - Street 1:800 MOUNT VERNON HWY NE STE 120
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4293
Mailing Address - Country:US
Mailing Address - Phone:770-804-1684
Mailing Address - Fax:770-804-1679
Practice Address - Street 1:3420 BUFORD DR
Practice Address - Street 2:SUITE C560
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4990
Practice Address - Country:US
Practice Address - Phone:770-831-7200
Practice Address - Fax:770-831-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2009019277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty