MEDICARE: OPTOMETRY CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	GA OPT1868	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083855704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOMETRY CLINIC, INC.

Provider Business Mailing Address
First Line	:	312 CASCADE CT
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-2805
Country	:	US
Telephone Number	:	706-593-0709
Fax Number	:	706-682-3931

Provider Business Practice Location Address
First Line	:	9220 MARNE RD
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31905-5515
Country	:	US
Telephone Number	:	706-682-3938
Fax Number	:	706-682-3931

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SMITESH JAY PATEL
Credential	:
Telephone Number	:	706-507-3937

Provider Enumeration Date	:	03/09/2009
Last Update Date	:	08/23/2022

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Directions to “OPTOMETRY CLINIC, INC. ” Practice Location

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