Provider Demographics
NPI:1396712816
Name:TA, MINH CONG (OD)
Entity type:Individual
Prefix:DR
First Name:MINH
Middle Name:CONG
Last Name:TA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1088 GRASSMEADE CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5501
Mailing Address - Country:US
Mailing Address - Phone:770-331-3926
Mailing Address - Fax:678-807-1158
Practice Address - Street 1:2570 BLACKMON DR STE 350
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6197
Practice Address - Country:US
Practice Address - Phone:678-846-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2022-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002034152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU97572Medicare UPIN