Healthcare Provider Details

I. General information

NPI: 1669745345
Provider Name (Legal Business Name): SOUTH GEORGIA EYE PARTNERS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2012
Last Update Date: 02/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DOCTORS DR SUITE 290
DOUGLAS GA
31533-2201
US

IV. Provider business mailing address

4380 KINGS WAY
VALDOSTA GA
31602-6921
US

V. Phone/Fax

Practice location:
  • Phone: 912-393-0055
  • Fax: 912-384-5976
Mailing address:
  • Phone: 229-244-2068
  • Fax: 229-244-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT H PETERMANN
Title or Position: OWNER
Credential: MD
Phone: 912-393-0055