Provider Demographics
NPI:1073660452
Name:LOOKING GLASS OPTICAL CONTACTS AND EYEGLASSES
Entity Type:Organization
Organization Name:LOOKING GLASS OPTICAL CONTACTS AND EYEGLASSES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:TELES
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:410-768-0202
Mailing Address - Street 1:8028 RITCHIE HWY
Mailing Address - Street 2:SUITE 124
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1075
Mailing Address - Country:US
Mailing Address - Phone:410-768-0202
Mailing Address - Fax:410-768-1330
Practice Address - Street 1:8028 RITCHIE HWY
Practice Address - Street 2:SUITE 124
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-1075
Practice Address - Country:US
Practice Address - Phone:410-768-0202
Practice Address - Fax:410-768-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT1680001OtherCAREFIRST OF DC
MDKEN4LOOtherCAREFIRST OF MARYLAND
MD603673OtherAETNA
MDT19632Medicare UPIN
MD970M774FMedicare ID - Type UnspecifiedMEDICARE ID#