Provider Demographics
NPI:1265526842
Name:GEWIRTZ, PAMELA S (OD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:S
Last Name:GEWIRTZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 ATLANTA HWY NW
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-7826
Mailing Address - Country:US
Mailing Address - Phone:770-868-5992
Mailing Address - Fax:770-868-1466
Practice Address - Street 1:440 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30024
Practice Address - Country:US
Practice Address - Phone:770-868-5992
Practice Address - Fax:770-868-1466
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1756152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA262989792AMedicaid
GAGRP7184Medicare PIN
GA262989792AMedicaid
41ZCFVQMedicare Oscar/Certification