Basic Information
| Provider Information | |||||||||
| NPI: | 1225208234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIVATE EYE VISION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 174 DANBURY RD | ||||||||
| Address2: | |||||||||
| City: | NEW MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067764328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603545537 | ||||||||
| FaxNumber: | 8603509340 | ||||||||
| Practice Location | |||||||||
| Address1: | 174 DANBURY RD | ||||||||
| Address2: | |||||||||
| City: | NEW MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067764328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603545537 | ||||||||
| FaxNumber: | 8603509340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | WAYAWOTZKI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8603545537 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0938 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.