Provider Demographics
NPI:1003877150
Name:ENNEN EYE CENTER, P.A.
Entity Type:Organization
Organization Name:ENNEN EYE CENTER, P.A.
Other - Org Name:ENNEN EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-452-7800
Mailing Address - Street 1:3312 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5052
Mailing Address - Country:US
Mailing Address - Phone:479-452-7800
Mailing Address - Fax:479-452-9486
Practice Address - Street 1:3312 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5052
Practice Address - Country:US
Practice Address - Phone:479-452-7800
Practice Address - Fax:479-452-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100177380BMedicaid
AR152215002Medicaid
AR4351100001Medicare NSC
5C372Medicare ID - Type Unspecified