Healthcare Provider Details

I. General information

NPI: 1225793250
Provider Name (Legal Business Name): DIGITAL VISION OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5582 MEMORIAL DR STE 201
STONE MOUNTAIN GA
30083-3215
US

IV. Provider business mailing address

5582 MEMORIAL DR STE 201
STONE MOUNTAIN GA
30083-3215
US

V. Phone/Fax

Practice location:
  • Phone: 678-335-6130
  • Fax: 678-335-6336
Mailing address:
  • Phone: 678-335-6130
  • Fax: 678-335-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: KEITH THOMPSON
Title or Position: MD., OWNER, AUTHORIZED OFFICIAL
Credential: MD
Phone: 678-335-6130