Provider Demographics
NPI:1801063680
Name:MICHAEL L SERRANO OD
Entity type:Organization
Organization Name:MICHAEL L SERRANO OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-868-5992
Mailing Address - Street 1:204 LAKE RUBY DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2397
Mailing Address - Country:US
Mailing Address - Phone:770-868-5992
Mailing Address - Fax:770-868-1466
Practice Address - Street 1:440 ATLANTA HWY NW
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-7826
Practice Address - Country:US
Practice Address - Phone:770-868-5992
Practice Address - Fax:770-868-1466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7184Medicare Oscar/Certification
GA41ZCFVPMedicare PIN
GAU81546Medicare UPIN