Provider Demographics
NPI:1184802670
Name:CLARKSON OPTOMETRY GEORGIA INC
Entity type:Organization
Organization Name:CLARKSON OPTOMETRY GEORGIA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-200-4393
Mailing Address - Street 1:PO BOX 207173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7173
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:8400 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITE 440
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1837
Practice Address - Country:US
Practice Address - Phone:636-200-4393
Practice Address - Fax:770-645-1210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001925152W00000X
GA001946152W00000X
GAOPT01946152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCGBJMedicare PIN
GAGRP7628Medicare PIN
GADQ4965Medicare PIN