Provider Demographics
NPI:1013444645
Name:DROW-OPTIMUM MULTISPECIALTY
Entity Type:Organization
Organization Name:DROW-OPTIMUM MULTISPECIALTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:D
Authorized Official - Last Name:DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-993-8374
Mailing Address - Street 1:3009 RAINBOW DR STE 139D
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1640
Mailing Address - Country:US
Mailing Address - Phone:770-743-6585
Mailing Address - Fax:
Practice Address - Street 1:3009 RAINBOW DR STE 139D
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1640
Practice Address - Country:US
Practice Address - Phone:770-743-6585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207KI0005X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory ImmunologyGroup - Multi-Specialty