Healthcare Provider Details

I. General information

NPI: 1841383122
Provider Name (Legal Business Name): ADVANCED EYECARE OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1569 N EXPRESSWAY
GRIFFIN GA
30223-1746
US

IV. Provider business mailing address

1118 HILLTOP DR
GRIFFIN GA
30224-4937
US

V. Phone/Fax

Practice location:
  • Phone: 770-233-6860
  • Fax:
Mailing address:
  • Phone: 770-233-6860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number819T
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier55413554SA
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: DR. JOHN WILLIAM BALDWIN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 770-233-6860