Provider Demographics
NPI:1811273899
Name:FORD, DIANA GAIL (OD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:GAIL
Last Name:FORD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 LINKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-2515
Mailing Address - Country:US
Mailing Address - Phone:770-557-5869
Mailing Address - Fax:
Practice Address - Street 1:1550 RIVERSTONE PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2918
Practice Address - Country:US
Practice Address - Phone:770-720-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-23
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU42561Medicare UPIN