1770679094 NPI number — EYE CONSULTANTS OF ATLANTA, PC

Table of content: DR. DAVID G VAN DE WYNGAERDE MD (NPI 1528065919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770679094 NPI number — EYE CONSULTANTS OF ATLANTA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CONSULTANTS OF ATLANTA, 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:
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:
1770679094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3225 CUMBERLAND BLVD SE
Provider Second Line Business Mailing Address:
SUITE 900
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-6407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-351-2220
Provider Business Mailing Address Fax Number:
404-591-2939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3225 CUMBERLAND BLVD SE
Provider Second Line Business Practice Location Address:
SUITE 800 OR 900
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30339-6407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-351-2220
Provider Business Practice Location Address Fax Number:
404-591-2939
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PERRY
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
404-351-2220

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GRP965 . This is a "MEDICARE ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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