Provider Demographics
NPI:1124114046
Name:SPETALNICK, THOMAS ALAN (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALAN
Last Name:SPETALNICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1065 JODECO RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4953
Mailing Address - Country:US
Mailing Address - Phone:678-284-6300
Mailing Address - Fax:678-284-6282
Practice Address - Street 1:800 MOUNT VERNON HWY
Practice Address - Street 2:SUITE 125
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4295
Practice Address - Country:US
Practice Address - Phone:404-256-1125
Practice Address - Fax:404-256-1964
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001121152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU21254Medicare UPIN