MEDICARE: JOHN E. TITAK 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	001466	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	:	1962461319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN E. TITAK O.D.

Provider Business Mailing Address
First Line	:	3 FAIRFIELD DR
Second Line	:
City	:	AVONDALE ESTATES
State	:	GA
Zip	:	30002-1421
Country	:	US
Telephone Number	:	678-432-3144
Fax Number	:	678-432-3420

Provider Business Practice Location Address
First Line	:	3 FAIRFIELD DR
Second Line	:
City	:	AVONDALE ESTATES
State	:	GA
Zip	:	30002-1421
Country	:	US
Telephone Number	:	678-432-3144
Fax Number	:	678-432-3420

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

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	03/31/2015

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