Healthcare Provider Details

I. General information

NPI: 1417730987
Provider Name (Legal Business Name): DAVID ANDREW HARTZOG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E LEE ST STE B
ENTERPRISE AL
36330-2477
US

IV. Provider business mailing address

31878 ANTIOCH RD
ANDALUSIA AL
36421-5912
US

V. Phone/Fax

Practice location:
  • Phone: 334-347-6599
  • Fax: 334-417-0190
Mailing address:
  • Phone: 334-343-2473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-F28-TA-D11
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: