Basic Information
Provider Information | |||||||||
NPI: | 1811998255 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE EYE DR'S, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1030 13TH ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319012240 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063278181 | ||||||||
FaxNumber: | 7065966658 | ||||||||
Practice Location | |||||||||
Address1: | 1030 13TH ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319012240 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063278181 | ||||||||
FaxNumber: | 7065966658 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2005 | ||||||||
LastUpdateDate: | 05/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOLD | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: | I | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7063247221 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 203217282 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 529924910 | 05 | AL |   | MEDICAID |