Provider Demographics
NPI:1649681768
Name:JING DONG MD PC
Entity type:Organization
Organization Name:JING DONG MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF REVENUE CYCLE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-990-7590
Mailing Address - Street 1:5 SOUTH MCINTOSH STREET
Mailing Address - Street 2:
Mailing Address - City:ELBERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30635
Mailing Address - Country:US
Mailing Address - Phone:706-546-9290
Mailing Address - Fax:706-546-4938
Practice Address - Street 1:5 S MCINTOSH ST
Practice Address - Street 2:
Practice Address - City:ELBERTON
Practice Address - State:GA
Practice Address - Zip Code:30635-2465
Practice Address - Country:US
Practice Address - Phone:706-283-7510
Practice Address - Fax:706-283-7570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2023-02-28
Deactivation Date:2019-06-11
Deactivation Code:
Reactivation Date:2019-07-03
Provider Licenses
StateLicense IDTaxonomies
GAOPT002405152W00000X
GAOPT002596152W00000X
GA045447207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000791568JMedicaid