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	:	1780266494
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	:	78205-2255
Country	:	US
Telephone Number	:	726-444-4078
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 CUMBERLAND MALL SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-3136
Country	:	US
Telephone Number	:	770-434-0440
Fax Number	:	770-434-5460

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW MARSICH
Credential	:	OD
Telephone Number	:	726-444-4078

Provider Enumeration Date	:	04/22/2021
Last Update Date	:	04/22/2021

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