Healthcare Provider Details

I. General information

NPI: 1033118096
Provider Name (Legal Business Name): RICHARD H BLUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 LANGFORD DR BUILDING 400, SUITE 101
BOGART GA
30622-2610
US

IV. Provider business mailing address

1747 LANGFORD DR BUILDING 400, SUITE 101
BOGART GA
30622-2610
US

V. Phone/Fax

Practice location:
  • Phone: 706-549-0005
  • Fax: 706-850-3180
Mailing address:
  • Phone: 706-549-0005
  • Fax: 706-850-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number027348
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: