1649681768 NPI number — JING DONG MD PC

Table of content: (NPI 1649681768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649681768 NPI number — JING DONG MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JING DONG MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GEORGIA CENTER FOR SIGHT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649681768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/11/2019
NPI Reactivation Date:
07/03/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 SOUTH MCINTOSH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELBERTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-546-9290
Provider Business Mailing Address Fax Number:
706-546-4938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 S MCINTOSH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELBERTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30635-2465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-283-7510
Provider Business Practice Location Address Fax Number:
706-283-7570
Provider Enumeration Date:
05/12/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
CANDICE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CHIEF REVENUE CYCLE OFFICER
Authorized Official Telephone Number:
916-990-7590

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT002405 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT002596 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 045447 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000791568J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".