Individual
GREGG E RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
895 CANTON RD NE, BUILDING 100, MARIETTA, GA 30060-8934
(770) 427-8111
(770) 499-1643
Mailing address
895 CANTON RD NE, BUILDING 100, MARIETTA, GA 30060-8934
(770) 427-8111
(770) 499-1643
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
001349
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000515787W
—
GA
Enumeration date
08/11/2005
Last updated
07/08/2007
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