=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609484773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | UYENTHU VO OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2020
-----------------------------------------------------
Last Update Date | 07/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 MARKETPLACE BLVD
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-8129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-346-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4437 BOATMANS CV
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-2483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-789-7904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT003242
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------