Provider Demographics
NPI:1316075476
Name:ROGOL, JOEL (OD)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:ROGOL
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 1:1434 SCOTT BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1424
Mailing Address - Country:US
Mailing Address - Phone:404-378-2622
Mailing Address - Fax:404-378-2681
Practice Address - Street 1:4030 LAWRENCEVILLE HWY NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2820
Practice Address - Country:US
Practice Address - Phone:770-806-8471
Practice Address - Fax:404-378-2681
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001637152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFGNMedicare ID - Type Unspecified
GAU60370Medicare UPIN