Basic Information
| Provider Information | |||||||||
| NPI: | 1265490395 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VISIQUE OPTOMETRY, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EYE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W WILLIAMS ST | ||||||||
| Address2: | SUITE 164 | ||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275025203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193620332 | ||||||||
| FaxNumber: | 9193620933 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W WILLIAMS ST | ||||||||
| Address2: | SUITE 164 | ||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275025203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193620332 | ||||||||
| FaxNumber: | 9193620933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 02/23/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | SANJAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9193620332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
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 | 5902115 | 05 | NC | MEDICAID |