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General NPI Number Information
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NPI Number | 1568253110
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Entity Type | Organization
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Legal Business Name | PEACH STATE RETINA, LLC
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Dates
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Enumeration Date | 05/14/2025
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Last Update Date | 10/27/2025
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Provider Practice Location Address
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Address Line | 3535 HIGHWAY 81
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City | LOGANVILLE
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State | GA
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Zip | 30052-4336
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Country | US
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Telephone | 770-520-8303
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Fax | 478-500-8205
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Provider Business Mailing Address
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Address Line | 3535 HIGHWAY 81
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City | LOGANVILLE
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State | GA
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Zip | 30052-4336
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Country | US
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Telephone | 770-520-8303
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Fax | 478-500-8205
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Authorized Official
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Title or Position | OWNER
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Name | DR. WILLIAM CARROLL
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Credential | MD
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Telephone | 478-374-7184
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207WX0107X
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Taxonomy Name | Retina Specialist (Ophthalmology) Physician
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License Number |
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License Number State |
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