Provider Demographics
NPI:1750073102
Name:PHILLIPS, MEGAN ANNICE (LDO)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ANNICE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 HWY 27 N BYP
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-1950
Mailing Address - Country:US
Mailing Address - Phone:770-537-6386
Mailing Address - Fax:
Practice Address - Street 1:404 HWY 27 N BYP
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-1950
Practice Address - Country:US
Practice Address - Phone:770-537-6386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2611156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician