Basic Information
| Provider Information | |||||||||
| NPI: | 1316021462 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MYEYEDR OPTOMETRY OF NORTH CAROLINA, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MYEYEDR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8614 WESTWOOD CENTER DR FL 9 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221822442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 584 CHURCH ST N | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280254573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047820677 | ||||||||
| FaxNumber: | 7042629772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 05/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | HEALEY | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 7038478899 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 05/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1849 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 37-1457054 | 01 | NC | CIGNA | OTHER | 16745 | 01 | NC | SPECTERA | OTHER | 2200491 | 01 | NC | UHC | OTHER | 37-1457054 | 01 | NC | PCHS | OTHER | 37-1457054 | 01 | NC | SUPERIOR VISION | OTHER | 89093MH | 05 | NC | MEDICAID | 2120312 | 01 | NC | MAMSI | OTHER | 37-1457054 | 01 | NC | HCS | OTHER | NC1849 | 01 | NC | EYEMED/ECPA | OTHER | 017AA | 01 | NC | BCBS | OTHER | 37-1457054 | 01 | NC | FHN | OTHER | 804276 | 01 | NC | COMMUNITY EYE CARE | OTHER |