MEDICARE: KEESHA K. HAMPTON 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	GAOPT002236	GA

General Provider Information

NPI Number	:	1811094246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEESHA K. HAMPTON O.D.

Provider Business Mailing Address
First Line	:	935 QUEENSBROOKE WAY
Second Line	:
City	:	MABLETON
State	:	GA
Zip	:	30126-6413
Country	:	US
Telephone Number	:	678-945-4673
Fax Number	:

Provider Business Practice Location Address
First Line	:	3615 CHARLES HARDY PKWY
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30157-9472
Country	:	US
Telephone Number	:	770-445-3938
Fax Number	:	770-445-0127

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	12/13/2022

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