Basic Information
Provider Information | |||||||||
NPI: | 1841248077 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MYEYEDR OPTOMETRY OF NORTH CAROLINA PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MYEYEDR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 3001 MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | NEW BERN | ||||||||
State: | NC | ||||||||
PostalCode: | 285625211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526332901 | ||||||||
FaxNumber: | 2526332902 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 05/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HEALEY | ||||||||
AuthorizedOfficialFirstName: | SUE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 7038478899 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/29/2022 |
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 | 09698 | 01 | NC | BCBS GRP # | OTHER | 7909698 | 05 | NC |   | MEDICAID |