Healthcare Provider Details

I. General information

NPI: 1942754759
Provider Name (Legal Business Name): BORIS SEVERINSKY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE BLDG B
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

1365 CLIFTON RD NE BLDG B
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-2020
  • Fax:
Mailing address:
  • Phone: 404-778-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5225
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT003068
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: