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General NPI Number Information
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NPI Number | 1801292016
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Entity Type | Individual
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Provider Name | OTIS WEAVER LICENSED OPTICIAN
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Gender | Male
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Dates
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Enumeration Date | 11/16/2014
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Last Update Date | 11/16/2014
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Provider Practice Location Address
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Address Line | 4765 MEMORIAL DR
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City | DECATUR
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State | GA
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Zip | 30032-1417
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Country | US
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Telephone | 404-296-2307
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Fax |
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Provider Business Mailing Address
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Address Line | 5391 RADFORD LN
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City | LITHONIA
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State | GA
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Zip | 30038-2899
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Country | US
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Telephone | 404-219-4309
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | LDO001204
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License Number State | GA
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