Provider Demographics
NPI:1871550426
Name:OVERALL, JERRY M (OD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:OVERALL
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 1:208 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2755
Mailing Address - Country:US
Mailing Address - Phone:706-882-0166
Mailing Address - Fax:706-883-7363
Practice Address - Street 1:208 SMITH ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2755
Practice Address - Country:US
Practice Address - Phone:706-882-0166
Practice Address - Fax:706-883-7363
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00004496AMedicaid
GA00004496AMedicaid