1962536896 NPI number — PENINSULA EYE CENTER, P.A.

Table of content: (NPI 1962536896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962536896 NPI number — PENINSULA EYE CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA EYE CENTER, P.A.
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:
6
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:
1962536896
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:
101 MILFORD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21804-6952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-749-9290
Provider Business Mailing Address Fax Number:
410-543-9087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 MILFORD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21804-6952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-749-9290
Provider Business Practice Location Address Fax Number:
410-543-9087
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUPPENS
Authorized Official First Name:
GARY
Authorized Official Middle Name:
PHILIP
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-749-9290

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  D0022099 , 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: H788PE . This is a "CAREFIRST BLUE CROSS BLUE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 08435300-01 . This is a "DMERC" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 44689 . This is a "DAVIS VISION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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