1518007491 NPI number — BETHESDA EYE CENTER, OPTOMETRY, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518007491 NPI number — BETHESDA EYE CENTER, OPTOMETRY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHESDA EYE CENTER, OPTOMETRY, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518007491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3111 MAPLEWOOD AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-3906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-765-8130
Provider Business Mailing Address Fax Number:
336-765-6403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3111 MAPLEWOOD AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-3906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-765-8130
Provider Business Practice Location Address Fax Number:
336-765-6403
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIOTT
Authorized Official First Name:
J GRADY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-765-8130

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1456 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2468143 . This is a "MEDICARE - PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8801962 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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