Provider Demographics
NPI:1396714416
Name:IRELAND, JUDSON RAY JR (OD)
Entity type:Individual
Prefix:DR
First Name:JUDSON
Middle Name:RAY
Last Name:IRELAND
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1675 LEE ROAD 248
Mailing Address - Street 2:
Mailing Address - City:SMITHS STATION
Mailing Address - State:AL
Mailing Address - Zip Code:36877-3213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6475 GATEWAY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-5636
Practice Address - Country:US
Practice Address - Phone:706-563-6449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000705152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55355354SBMedicare Oscar/Certification