Provider Demographics
NPI:1144366212
Name:ACADEMY OF CATARACT AND LASER SURGERY, PC
Entity type:Organization
Organization Name:ACADEMY OF CATARACT AND LASER SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:BRUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-722-9601
Mailing Address - Street 1:909 15TH ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2607
Practice Address - Country:US
Practice Address - Phone:706-722-9601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014605207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA014605OtherGA STATE LICENSE
GA240279OtherBLUE CROSS OF GA
GA014605OtherGA STATE LICENSE