Provider Demographics
NPI:1033694179
Name:DIXWELL AVENUE EYECARE PLLC
Entity Type:Organization
Organization Name:DIXWELL AVENUE EYECARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-767-9169
Mailing Address - Street 1:531 FAIRFIELD BEACH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6740
Mailing Address - Country:US
Mailing Address - Phone:203-767-9169
Mailing Address - Fax:
Practice Address - Street 1:2100 DIXWELL AVE STE 16
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-2406
Practice Address - Country:US
Practice Address - Phone:203-281-4330
Practice Address - Fax:203-288-4018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008036359Medicaid