Basic Information
Provider Information | |||||||||
NPI: | 1780865220 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OPHTHALMOLOGY CONSULTANTS, LLC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12990 MANCHESTER RD | ||||||||
Address2: | 201 | ||||||||
City: | DES PERES | ||||||||
State: | MO | ||||||||
PostalCode: | 631311804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149090633 | ||||||||
FaxNumber: | 3149090391 | ||||||||
Practice Location | |||||||||
Address1: | 12990 MANCHESTER RD | ||||||||
Address2: | 201 | ||||||||
City: | DES PERES | ||||||||
State: | MO | ||||||||
PostalCode: | 631311804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149090633 | ||||||||
FaxNumber: | 3149090391 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/26/2007 | ||||||||
LastUpdateDate: | 03/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DONAHOE | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | P. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
AuthorizedOfficialTelephone: | 3149090633 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 03/11/2021 |
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 |