Provider Demographics
NPI:1033528112
Name:MARYLAND VISION INSTITUTE, LLC
Entity Type:Organization
Organization Name:MARYLAND VISION INSTITUTE, LLC
Other - Org Name:MARYLAND VISION INSTITUTE OPTICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:
Authorized Official - Last Name:VITTETOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-791-0888
Mailing Address - Street 1:220 CHAMPION DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6558
Mailing Address - Country:US
Mailing Address - Phone:301-791-0888
Mailing Address - Fax:301-791-3611
Practice Address - Street 1:220 CHAMPION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6558
Practice Address - Country:US
Practice Address - Phone:301-791-0888
Practice Address - Fax:301-791-3611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6503039Medicaid