Provider Demographics
NPI:1053417956
Name:BANNISTER, RON M (OD)
Entity type:Individual
Prefix:
First Name:RON
Middle Name:M
Last Name:BANNISTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:102 S DAWSON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5185
Mailing Address - Country:US
Mailing Address - Phone:229-226-9190
Mailing Address - Fax:229-226-8824
Practice Address - Street 1:15196 US HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31757-4820
Practice Address - Country:US
Practice Address - Phone:229-228-4770
Practice Address - Fax:229-225-9060
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000844152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0271120001OtherDME-MEDICARE
GA40064OtherAVESIS PIN
GA000139334AMedicaid
GA000139334AMedicaid
GAT47964Medicare UPIN