Basic Information
| Provider Information | |||||||||
| NPI: | 1659799575 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPHTHALMOLOGY CONSULTANTS, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | SUITE 5006B | ||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144325478 | ||||||||
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| Practice Location | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | SUITE 5006B | ||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144325478 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2014 | ||||||||
| LastUpdateDate: | 03/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | DONAHOE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3149090633 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 507243301 | 05 | MO | MEDICAID |