MEDICARE: DR. RENEE CANDACE AHLMARK-GORDON OD

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	OPT002136	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	:	1376539445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RENEE CANDACE AHLMARK-GORDON OD

Provider Business Mailing Address
First Line	:	1569 US HIGHWAY 19 S
Second Line	:
City	:	LEESBURG
State	:	GA
Zip	:	31763-4939
Country	:	US
Telephone Number	:	229-439-1200
Fax Number	:	229-255-2929

Provider Business Practice Location Address
First Line	:	1569 US HIGHWAY 19 S
Second Line	:
City	:	LEESBURG
State	:	GA
Zip	:	31763-4939
Country	:	US
Telephone Number	:	229-439-1200
Fax Number	:	229-255-2929

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

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	03/29/2023

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