Provider Demographics
NPI:1205132552
Name:NA, ROBERT S (LDO)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:S
Last Name:NA
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:310 TOWN CENTER AVE
Mailing Address - Street 2:SUITE A1
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6856
Mailing Address - Country:US
Mailing Address - Phone:678-468-7525
Mailing Address - Fax:678-482-1668
Practice Address - Street 1:310 TOWN CENTER AVE
Practice Address - Street 2:SUITE A1
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6856
Practice Address - Country:US
Practice Address - Phone:678-468-7525
Practice Address - Fax:678-482-1668
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001684156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician