Healthcare Provider Details

I. General information

NPI: 1922253111
Provider Name (Legal Business Name): HECTOR JOSE MALLAR O.D., F.A.A.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 FURYS FERRY RD
AUGUSTA GA
30907-9059
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 706-860-8899
  • Fax: 706-863-7822
Mailing address:
  • Phone: 703-847-8899
  • Fax: 866-795-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT001286
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPT001286
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001286
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: