Provider Demographics
NPI:1215926233
Name:MOBLEY, BENNIE DEAN (OD)
Entity type:Individual
Prefix:
First Name:BENNIE
Middle Name:DEAN
Last Name:MOBLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3999 HWY 34 EAST
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277
Mailing Address - Country:US
Mailing Address - Phone:770-304-2025
Mailing Address - Fax:678-854-9941
Practice Address - Street 1:3999 HWY 34 EAST
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277
Practice Address - Country:US
Practice Address - Phone:770-304-2025
Practice Address - Fax:678-854-9941
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000912152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCDSBOtherMEDICARE PTAN
GA00214629CMedicaid
41ZCDPROtherMEDICARE PTAN
GA582481591Medicare UPIN
GA0531050001Medicare NSC