Provider Demographics
NPI:1912294984
Name:PHLONG, CAREY JENKINS (OD)
Entity Type:Individual
Prefix:
First Name:CAREY
Middle Name:JENKINS
Last Name:PHLONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CAREY
Other - Middle Name:MICHELLE
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1000 CORPORATE CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-4106
Mailing Address - Country:US
Mailing Address - Phone:770-968-8888
Mailing Address - Fax:770-860-2473
Practice Address - Street 1:1000 CORPORATE CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-4106
Practice Address - Country:US
Practice Address - Phone:770-968-8888
Practice Address - Fax:770-860-2473
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT2644152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112940AMedicaid
581787543OtherFEIN
GA003112940AMedicaid