Provider Demographics
NPI:1952570756
Name:K. DELTON HARTZOG, O.D.
Entity Type:Organization
Organization Name:K. DELTON HARTZOG, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DELTON
Authorized Official - Last Name:HARTZOG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:256-546-4647
Mailing Address - Street 1:249 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-4102
Mailing Address - Country:US
Mailing Address - Phone:256-546-4647
Mailing Address - Fax:256-546-4272
Practice Address - Street 1:249 S 6TH ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-4102
Practice Address - Country:US
Practice Address - Phone:256-546-4647
Practice Address - Fax:256-546-4272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS357TA046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT68932Medicare UPIN