Provider Demographics
NPI:1194995175
Name:B.DEAN MOBLEY, O.D., P.C.
Entity type:Organization
Organization Name:B.DEAN MOBLEY, O.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-941-2323
Mailing Address - Street 1:3999 AUSTELL RD
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1100
Mailing Address - Country:US
Mailing Address - Phone:770-941-2323
Mailing Address - Fax:770-941-9220
Practice Address - Street 1:3999 AUSTELL RD
Practice Address - Street 2:SUITE 1002
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1100
Practice Address - Country:US
Practice Address - Phone:770-941-2323
Practice Address - Fax:770-941-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2011-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000912152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00214629AMedicaid
GAU10510Medicare UPIN
GA41ZCDSBMedicare PIN
GA00214629AMedicaid