Provider Demographics
NPI:1255364774
Name:SAMUELS, KATHY ANN (OD)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:ANN
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N PEACHTREE PKWY
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1743
Mailing Address - Country:US
Mailing Address - Phone:404-861-7253
Mailing Address - Fax:404-264-9549
Practice Address - Street 1:1201 N PEACHTREE PKWY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1743
Practice Address - Country:US
Practice Address - Phone:404-861-7253
Practice Address - Fax:404-264-9459
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFHLMedicare ID - Type Unspecified
GAU50556Medicare UPIN
GAGRP5067Medicare ID - Type Unspecified