Healthcare Provider Details

I. General information

NPI: 1871550426
Provider Name (Legal Business Name): JERRY M OVERALL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 SMITH ST
LAGRANGE GA
30240-2755
US

IV. Provider business mailing address

208 SMITH ST
LAGRANGE GA
30240-2755
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-0166
  • Fax: 706-883-7363
Mailing address:
  • Phone: 706-882-0166
  • Fax: 706-883-7363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT000678
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: