Provider Demographics
NPI:1013212133
Name:CUSTOM VISION CARE ASSOCIATES PA
Entity Type:Organization
Organization Name:CUSTOM VISION CARE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-498-1700
Mailing Address - Street 1:1615 12TH AVE RD STE B
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6184
Mailing Address - Country:US
Mailing Address - Phone:208-498-1700
Mailing Address - Fax:
Practice Address - Street 1:1615 12TH AVE RD STE B
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6184
Practice Address - Country:US
Practice Address - Phone:208-498-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty