Basic Information
Provider Information | |||||||||
NPI: | 1720237217 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EYE CARE ASSOCIATES OF MIDDLE GA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 198 S HOUSTON LAKE RD | ||||||||
Address2: | STE B | ||||||||
City: | WARNER ROBINS | ||||||||
State: | GA | ||||||||
PostalCode: | 310886473 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4789711500 | ||||||||
FaxNumber: | 4789712112 | ||||||||
Practice Location | |||||||||
Address1: | 2485 N COLUMBIA ST | ||||||||
Address2: | STE 118 | ||||||||
City: | MILLEDGEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 310615421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4784526569 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2008 | ||||||||
LastUpdateDate: | 09/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHRISTIE | ||||||||
AuthorizedOfficialFirstName: | DUDLEY | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4789711500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT001236 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.