Basic Information
| Provider Information | |||||||||
| NPI: | 1912294984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHLONG | ||||||||
| FirstName: | CAREY | ||||||||
| MiddleName: | JENKINS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENKINS | ||||||||
| OtherFirstName: | CAREY | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 CORPORATE CENTER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302604106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709688888 | ||||||||
| FaxNumber: | 7708602473 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 CORPORATE CENTER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302604106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709688888 | ||||||||
| FaxNumber: | 7708602473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 09/26/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT2644 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 003112940A | 05 | GA | MEDICAID | 581787543 | 01 | FEIN | OTHER |