Basic Information
| Provider Information | |||||||||
| NPI: | 1730520321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DITMETAROJ | ||||||||
| FirstName: | NASH | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045045678 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2400 MOUNT ZION PKWY | ||||||||
| Address2: | KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER | ||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789063173 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2013 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0002753 | GA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT002753 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.