MEDICARE: JEFFREY A STOVALL JR. 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	1174	GA

General Provider Information

NPI Number	:	1942440169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY A STOVALL JR. OD

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2009
Last Update Date	:	02/10/2022

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