MEDICARE: SOUTHEASTERN EYE CLINIC PC

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	OPTO01603	GA

General Provider Information

NPI Number	:	1225199979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN EYE CLINIC PC

Provider Business Mailing Address
First Line	:	214 SAVANNAH AVE
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5165
Country	:	US
Telephone Number	:	912-764-5609
Fax Number	:	912-764-7786

Provider Business Practice Location Address
First Line	:	214 SAVANNAH AVE
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5165
Country	:	US
Telephone Number	:	912-764-5609
Fax Number	:	912-764-7786

Authorized Official
Title or Position	:	OWNER, PROVIDER
Name	:	HORACE E DEAL
Credential	:	OD
Telephone Number	:	912-764-5609

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	06/24/2024

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