Provider Demographics
NPI:1174831887
Name:KNOXVILLE PEDIATRIC OPHTHALMOLOGY, PLLC
Entity Type:Organization
Organization Name:KNOXVILLE PEDIATRIC OPHTHALMOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:F
Authorized Official - Last Name:STOFFLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-521-7998
Mailing Address - Street 1:2100 W CLINCH AVE
Mailing Address - Street 2:SUITE 400 KOPPEL PLAZA
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2219
Mailing Address - Country:US
Mailing Address - Phone:865-521-7998
Mailing Address - Fax:865-521-7405
Practice Address - Street 1:2100 W CLINCH AVE
Practice Address - Street 2:SUITE 400 KOPPEL PLAZA
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2219
Practice Address - Country:US
Practice Address - Phone:865-521-7998
Practice Address - Fax:865-521-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14247207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3196142Medicaid
3196142Medicare PIN
TN3196142Medicaid