Basic Information
| Provider Information | |||||||||
| NPI: | 1699810986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINSTON EYE ASSOCIATES OD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2630 PETERS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271275655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367853486 | ||||||||
| FaxNumber: | 3367853002 | ||||||||
| Practice Location | |||||||||
| Address1: | 2630 PETERS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271275655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367853486 | ||||||||
| FaxNumber: | 3367853002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3367853486 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 8909985 | 05 | NC | MEDICAID | 09985 | 01 | NC | BLUECROSS | OTHER | 410034342 | 01 | NC | RR MCR# | OTHER |