Basic Information
| Provider Information | |||||||||
| NPI: | 1184802670 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARKSON OPTOMETRY GEORGIA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CLARKSON EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207173 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 8400 HOLCOMB BRIDGE RD | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300221837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 7706451210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WACHTER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 6362004393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 001925 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | 001946 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT01946 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.