Provider Demographics
NPI:1487753141
Name:HENDRICKS, TIMOTHY DALE (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DALE
Last Name:HENDRICKS
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 1:1000 TOWNE CENTER BLVD
Mailing Address - Street 2:SUITE 502
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4052
Mailing Address - Country:US
Mailing Address - Phone:912-748-1272
Mailing Address - Fax:912-748-1996
Practice Address - Street 1:1000 TOWNE CENTER BLVD
Practice Address - Street 2:SUITE 502
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4052
Practice Address - Country:US
Practice Address - Phone:912-748-1272
Practice Address - Fax:912-748-1996
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT 002025152W00000X
SCSC 1345152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDAG 979Medicaid
GAU90681Medicare UPIN
SCDAG 979Medicaid