Healthcare Provider Details

I. General information

NPI: 1396274478
Provider Name (Legal Business Name): REBECCA GOAD OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NEWNAN ST
CARROLLTON GA
30117-3225
US

IV. Provider business mailing address

119 MAPLE ST STE 205
CARROLLTON GA
30117-3259
US

V. Phone/Fax

Practice location:
  • Phone: 931-436-5382
  • Fax:
Mailing address:
  • Phone: 931-436-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3018
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: