Healthcare Provider Details

I. General information

NPI: 1194750265
Provider Name (Legal Business Name): CARLOS M LLABRES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. CARLOS M LLABRES

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1862 JONESBORO RD
MCDONOUGH GA
30253-5960
US

IV. Provider business mailing address

11103 WEST AVE 6
SAN ANTONIO TX
78213-1370
US

V. Phone/Fax

Practice location:
  • Phone: 678-432-1584
  • Fax: 678-432-6258
Mailing address:
  • Phone: 210-524-6663
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001480
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1480T
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: