Basic Information
Provider Information | |||||||||
NPI: | 1770677627 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KONSHAK | ||||||||
FirstName: | ANNE-MARIE | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1061 HARMON AVE | ||||||||
Address2: | STE 1D03 | ||||||||
City: | FORT STEWART | ||||||||
State: | GA | ||||||||
PostalCode: | 313145611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124356933 | ||||||||
FaxNumber: | 9124355966 | ||||||||
Practice Location | |||||||||
Address1: | 1061 HARMON AVE | ||||||||
Address2: | STE 1D03 | ||||||||
City: | FORT STEWART | ||||||||
State: | GA | ||||||||
PostalCode: | 313145611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124356933 | ||||||||
FaxNumber: | 9124355966 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6937T | TX | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.