Provider Demographics
NPI:1366540007
Name:JOHN E IMHOFF MD PC
Entity type:Organization
Organization Name:JOHN E IMHOFF MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:IMHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-267-0565
Mailing Address - Street 1:3215 SHRINE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520
Mailing Address - Country:US
Mailing Address - Phone:912-267-0565
Mailing Address - Fax:912-267-0545
Practice Address - Street 1:3215 SHRINE
Practice Address - Street 2:SUITE 6
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520
Practice Address - Country:US
Practice Address - Phone:912-267-0565
Practice Address - Fax:912-267-0545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001640152W00000X
GA023995207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MV0698538OtherDEA RICHARD A VAN DE VELD
AL1411951OtherDEA JOHN IMHOFF MD
GRP1900Medicare ID - Type UnspecifiedRICHARD A VAN DE VELDE OD
MV0698538OtherDEA RICHARD A VAN DE VELD
GRP1900Medicare ID - Type UnspecifiedJOHN IMHOFF MD
T33208Medicare UPIN