Basic Information
| Provider Information | |||||||||
| NPI: | 1952634206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMAN | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | FELIPE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 335 W PONCE DE LEON AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300302451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043773937 | ||||||||
| FaxNumber: | 4043773936 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 W PONCE DE LEON AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300302451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043773937 | ||||||||
| FaxNumber: | 4043773936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 09/17/2009 | ||||||||
| 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 | 156FX1800X | LDO 002182 | GA | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.