Healthcare Provider Details

I. General information

NPI: 1033791744
Provider Name (Legal Business Name): GA DOCTORS OF OPTOMETRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 PAVILION PKWY
FAYETTEVILLE GA
30214-4098
US

IV. Provider business mailing address

175 E HOUSTON ST
SAN ANTONIO TX
78205-2255
US

V. Phone/Fax

Practice location:
  • Phone: 678-817-4875
  • Fax: 678-817-4608
Mailing address:
  • Phone: 726-444-4078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW MARSICH
Title or Position: OWNER
Credential: OD
Phone: 726-444-4078