Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | 027348 | GA |
NPI | 1033118096 |
---|---|
Provider Name | Richard H Blue |
First Address | Bogart, GA 30622-2610 |
Second Address | Bogart, GA 30622-2610 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2005 |
Last Update Date | 24/02/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00301793A | (05) | GA |
024215 | BLUE CROSS BLUE SHEILD (01) | GA |
C06704 | (02) | GA |