Provider Demographics
NPI:1629287214
Name:BURNETT, JEFFREY SR (LDO)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:BURNETT
Suffix:SR
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6945 DEER CREEK TRCE
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5477
Mailing Address - Country:US
Mailing Address - Phone:404-918-1916
Mailing Address - Fax:678-267-2865
Practice Address - Street 1:6945 DEER CREEK TRCE
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-5477
Practice Address - Country:US
Practice Address - Phone:404-918-1916
Practice Address - Fax:678-267-2865
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2104156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician