1689298457 NPI number — NORTHEAST GEORGIA OPHTHALMOLOGY, LLC

Table of content: (NPI 1689298457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689298457 NPI number — NORTHEAST GEORGIA OPHTHALMOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST GEORGIA OPHTHALMOLOGY, LLC
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:
Provider Other Organization Name Type Code:
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:
1689298457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
195 14TH ST NE UNIT 805
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-2673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-596-8605
Provider Business Mailing Address Fax Number:
713-903-7907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1498 JESSE JEWELL PKWY SE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-596-8605
Provider Business Practice Location Address Fax Number:
713-903-7907
Provider Enumeration Date:
06/08/2020

Additional Information

Authorized Official

Authorized Official Last Name:
REDDY
Authorized Official First Name:
VANDANA
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
770-767-3937

Provider Taxonomy Codes

  • Taxonomy code: 261QS0132X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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