Provider Demographics
NPI:1881729788
Name:UNDERWOOD, TERRELL THOMPSON (LDO)
Entity type:Individual
Prefix:MR
First Name:TERRELL
Middle Name:THOMPSON
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:805 COMMERCE DR SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-6606
Mailing Address - Country:US
Mailing Address - Phone:770-483-4831
Mailing Address - Fax:770-483-4840
Practice Address - Street 1:805 COMMERCE DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6606
Practice Address - Country:US
Practice Address - Phone:770-483-4831
Practice Address - Fax:770-483-4840
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO000310156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0255320001Medicare NSC