Provider Demographics
NPI:1053488544
Name:COOSA EYE ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:COOSA EYE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:P. DUNCAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROY
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:256-378-5507
Mailing Address - Street 1:PO BOX J
Mailing Address - Street 2:
Mailing Address - City:CHILDERSBURG
Mailing Address - State:AL
Mailing Address - Zip Code:35044-0510
Mailing Address - Country:US
Mailing Address - Phone:256-378-5507
Mailing Address - Fax:256-378-5325
Practice Address - Street 1:34011 US HIGHWAY 280
Practice Address - Street 2:
Practice Address - City:CHILDERSBURG
Practice Address - State:AL
Practice Address - Zip Code:35044-2128
Practice Address - Country:US
Practice Address - Phone:256-378-5507
Practice Address - Fax:256-378-5325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-471-TA-079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-59662OtherBLUE CROSS
AL000059662Medicaid
AL102G703418OtherMEDICARE ID
AL000059662Medicaid
AL000059662Medicare ID - Type Unspecified
AL000059662Medicaid