Provider Demographics
NPI:1386741023
Name:CONSOR, BRUCE (OD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:CONSOR
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 1:610 PORTICO PT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4717
Mailing Address - Country:US
Mailing Address - Phone:770-317-5283
Mailing Address - Fax:
Practice Address - Street 1:610 PORTICO PT
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-4717
Practice Address - Country:US
Practice Address - Phone:770-317-5283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist