1487864062 NPI number — CHESAPEAKE BAY OPTICAL

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 1487864062 NPI number — CHESAPEAKE BAY OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESAPEAKE BAY OPTICAL
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:
1487864062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2003 MEDICAL PARKWAY
Provider Second Line Business Mailing Address:
SUITE G90
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-841-1909
Provider Business Mailing Address Fax Number:
410-571-8624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2003 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE G90
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-7992
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-841-1909
Provider Business Practice Location Address Fax Number:
410-571-8624
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COCKRAN
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTICIAN
Authorized Official Telephone Number:
410-841-1909

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  02207819 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02207819 . This is a "STATE LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: XY29CH . This is a "BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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