MEDICARE: BENNIE DEAN MOBLEY O.D.

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	OPT000912	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41ZCDSB	OTHER	GA	MEDICARE PTAN
3	41ZCDPR	OTHER		MEDICARE PTAN

Other Identifiers

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

General Provider Information

NPI Number	:	1215926233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENNIE DEAN MOBLEY O.D.

Provider Business Mailing Address
First Line	:	3999 HWY 34 EAST
Second Line	:
City	:	SHARPSBURG
State	:	GA
Zip	:	30277
Country	:	US
Telephone Number	:	770-304-2025
Fax Number	:	678-854-9941

Provider Business Practice Location Address
First Line	:	3999 HWY 34 EAST
Second Line	:
City	:	SHARPSBURG
State	:	GA
Zip	:	30277
Country	:	US
Telephone Number	:	770-304-2025
Fax Number	:	678-854-9941

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	10/28/2022

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Directions to “ BENNIE DEAN MOBLEY O.D.” Practice Location

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