Healthcare Provider Details

I. General information

NPI: 1972734226
Provider Name (Legal Business Name): SCOTT EYE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 MARIETTA HWY STE 110
DALLAS GA
30157-3317
US

IV. Provider business mailing address

4075 MARIETTA HWY STE 110
DALLAS GA
30157-3317
US

V. Phone/Fax

Practice location:
  • Phone: 770-445-9866
  • Fax: 770-445-8244
Mailing address:
  • Phone: 770-445-9866
  • Fax: 770-445-8244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number1253
License Number StateGA

VIII. Authorized Official

Name: DR. ROGER WILKIN SCOTT JR.
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 770-445-9866