Provider Demographics
NPI:1316343452
Name:TIFTON OPHTHALMOLOGY ASSOCIATES. PC
Entity type:Organization
Organization Name:TIFTON OPHTHALMOLOGY ASSOCIATES. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-386-2181
Mailing Address - Street 1:1803 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1617
Mailing Address - Country:US
Mailing Address - Phone:229-386-2181
Mailing Address - Fax:229-386-2193
Practice Address - Street 1:1803 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1617
Practice Address - Country:US
Practice Address - Phone:229-386-2181
Practice Address - Fax:229-386-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACC44356OtherRAILROAD MEDICARE
GA300022683AMedicaid
GAGRP2612OtherGEORGIA MEDICARE