Basic Information
| Provider Information | |||||||||
| NPI: | 1184774846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURRAY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | WINSLETTE | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1061 HARMON AVE STE 1D03 | ||||||||
| Address2: | |||||||||
| City: | FORT STEWART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313145641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124355965 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3801 NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784751600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | OPT1862 | GA | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 1909 | SC | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000883451A | 05 | GA | MEDICAID |