MEDICARE: MYEYEDR. OPTOMETRY OF GEORGIA, 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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1861145955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYEYEDR. OPTOMETRY OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	8614 WESTWOOD CENTER DR FL 9
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-2442
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	1570 OLD ALABAMA RD STE 106
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-2108
Country	:	US
Telephone Number	:	770-557-0039
Fax Number	:	678-623-3108

Authorized Official
Title or Position	:	SECRETARY
Name	:	SUE DOWNES
Credential	:
Telephone Number	:	703-847-8899

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	05/26/2022

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