Provider Demographics
NPI:1154451219
Name:CAPITAL EYE PHYSICIANS & SURGEONS, LLC
Entity Type:Organization
Organization Name:CAPITAL EYE PHYSICIANS & SURGEONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KAUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:CSA
Authorized Official - Phone:301-809-6305
Mailing Address - Street 1:4000 MITCHELLVILLE RD
Mailing Address - Street 2:SUITE B-128
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3104
Mailing Address - Country:US
Mailing Address - Phone:301-809-6305
Mailing Address - Fax:301-809-6306
Practice Address - Street 1:4000 MITCHELLVILLE RD
Practice Address - Street 2:SUITE B-128
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3104
Practice Address - Country:US
Practice Address - Phone:301-809-6305
Practice Address - Fax:301-809-6306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD689701103Medicaid
MD689701100Medicaid
MD689701103Medicaid