Basic Information
| Provider Information | |||||||||
| NPI: | 1154410918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEPOE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLISH | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 550 EAGLES LANDING PARKWAY | ||||||||
| Address2: | STE 208 | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704741237 | ||||||||
| FaxNumber: | 7704745224 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 EAGLES LANDING PARKWAY | ||||||||
| Address2: | STE 208 | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704741237 | ||||||||
| FaxNumber: | 7704745224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 03/05/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT001486 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.