Healthcare Provider Details

I. General information

NPI: 1164833380
Provider Name (Legal Business Name): JING DONG MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2014
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date: 06/11/2019
Reactivation Date: 07/03/2019

III. Provider practice location address

1110 COMMERCE DR SUITE 112
GREENSBORO GA
30642-7444
US

IV. Provider business mailing address

1110 COMMERCE DR SUITE 112
GREENSBORO GA
30642-7444
US

V. Phone/Fax

Practice location:
  • Phone: 706-453-1922
  • Fax: 706-453-1926
Mailing address:
  • Phone: 706-453-1922
  • Fax: 706-453-1926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002405
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002596
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number045447
License Number StateGA

VIII. Authorized Official

Name: JING DONG
Title or Position: OWNER
Credential: MD, PHD
Phone: 706-546-9290