MEDICARE: GA DOCTORS OF OPTOMETRY LLC

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1275247827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GA DOCTORS OF OPTOMETRY LLC

Provider Business Mailing Address
First Line	:	175 E HOUSTON ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78205-2299
Country	:	US
Telephone Number	:	800-340-0129
Fax Number	:	210-524-6587

Provider Business Practice Location Address
First Line	:	1215 CAROLINE ST NE STE H100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30307-2775
Country	:	US
Telephone Number	:	470-610-2359
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	DOLSIE MCDONALD
Credential	:
Telephone Number	:	726-444-4078

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	01/09/2023

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