=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982831756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN EYES OF GEORGIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2009
-----------------------------------------------------
Last Update Date | 03/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3420 BUFORD DR SUITE C560
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-4990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-831-7200
-----------------------------------------------------
Fax | 770-831-0076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 MOUNT VERNON HWY NE STE 120
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-4293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-804-1684
-----------------------------------------------------
Fax | 770-804-1679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. DAVID WILLIAM DUDOVITZ
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 770-831-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2009019277
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------