Basic Information
| Provider Information | |||||||||
| NPI: | 1003479510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OBX OPTIX OPTOMETRIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5569 N CROATAN HWY | ||||||||
| Address2: | |||||||||
| City: | KITTY HAWK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279493996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524412000 | ||||||||
| FaxNumber: | 2524411834 | ||||||||
| Practice Location | |||||||||
| Address1: | 5569 N CROATAN HWY | ||||||||
| Address2: | |||||||||
| City: | KITTY HAWK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279493996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524412000 | ||||||||
| FaxNumber: | 2524411834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2524412000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1407812530 | 01 | BCBS NC | OTHER |