Provider Demographics
NPI:1053646570
Name:EYE GUYS
Entity Type:Organization
Organization Name:EYE GUYS
Other - Org Name:THE EYE GUYS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:GODNIG
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:907-439-3917
Mailing Address - Street 1:390 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7017
Mailing Address - Country:US
Mailing Address - Phone:907-376-3917
Mailing Address - Fax:907-376-3967
Practice Address - Street 1:390 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7017
Practice Address - Country:US
Practice Address - Phone:907-376-3917
Practice Address - Fax:907-376-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
161057OtherMEDICARE PTAN
AKOD4478Medicaid