Provider Demographics
NPI:1124151907
Name:EDWARD H POTTLITZER OD PC
Entity type:Organization
Organization Name:EDWARD H POTTLITZER OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:HERMAN
Authorized Official - Last Name:POTTLITZER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-949-4223
Mailing Address - Street 1:2911 CHAPEL HILL RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135
Mailing Address - Country:US
Mailing Address - Phone:770-949-4223
Mailing Address - Fax:770-949-4994
Practice Address - Street 1:2911 CHAPEL HILL RD
Practice Address - Street 2:SUITE 210
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135
Practice Address - Country:US
Practice Address - Phone:770-949-4223
Practice Address - Fax:770-949-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA79949Medicaid
GA0869160001Medicare ID - Type Unspecified