NPIMap

Organization Active NPI

Wildwood Eye Care LLC

  • Optometrist
  • Marietta, GA
National Provider Identifier
1396073862
Registry record updated Aug 1, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
WILDWOOD EYE CARE LLC
Practice address
1545 Powers Ferry Rd
Suite 240
Marietta, GA 30067-9412
Phone
(770) 952-6412
Fax
(770) 953-2738
NPI assigned
Nov 22, 2009
Last updated
Aug 1, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 1, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
David Grosswald, OD
Title
Manager
Phone
(770) 952-6412

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X Primary

Addresses

Primary practice location

1545 Powers Ferry Rd
Suite 240
Marietta, GA 30067-9412

Mailing address

1545 Powers Ferry Rd
Suite 240
Marietta, GA 30067-9412
Phone (770) 952-6412

Other names 1

  • Wildwood Eye Care Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100224000431 GA Part B Supplier - Clinic/Group Practice 5890839138 Receives reassigned benefits from 5 practitioners
1 other NPI on this enrollment
Practice locations: Dawsonville, GA; Marietta, GA

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Dawson Vision2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1258848000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1722470400000",
    "number": "1396073862",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1545 POWERS FERRY RD",
            "address_2": "SUITE 240",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300679412",
            "telephone_number": "770-952-6412",
            "fax_number": "770-953-2738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1545 POWERS FERRY RD",
            "address_2": "SUITE 240",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300679412",
            "telephone_number": "770-952-6412",
            "fax_number": "770-953-2738"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILDWOOD EYE CARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-22",
        "last_updated": "2024-08-01",
        "certification_date": "2024-08-01",
        "status": "A",
        "authorized_official_last_name": "GROSSWALD",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "770-952-6412",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wildwood Eye Care",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Marietta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.