Basic Information
Provider Information | |||||||||
NPI: | 1316343452 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TIFTON OPHTHALMOLOGY ASSOCIATES. PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1803 OLD OCILLA RD | ||||||||
Address2: |   | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317941617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293862181 | ||||||||
FaxNumber: | 2293862193 | ||||||||
Practice Location | |||||||||
Address1: | 1803 OLD OCILLA RD | ||||||||
Address2: |   | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317941617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293862181 | ||||||||
FaxNumber: | 2293862193 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2014 | ||||||||
LastUpdateDate: | 11/18/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOORMAN | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2293862181 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X |   | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | CC44356 | 01 | GA | RAILROAD MEDICARE | OTHER | 300022683A | 05 | GA |   | MEDICAID | GRP2612 | 01 | GA | GEORGIA MEDICARE | OTHER |