Provider Demographics
NPI:1225208234
Name:PRIVATE EYE VISION CENTER
Entity Type:Organization
Organization Name:PRIVATE EYE VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WAYAWOTZKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-354-5537
Mailing Address - Street 1:174 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-4328
Mailing Address - Country:US
Mailing Address - Phone:860-354-5537
Mailing Address - Fax:860-350-9340
Practice Address - Street 1:174 DANBURY RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-4328
Practice Address - Country:US
Practice Address - Phone:860-354-5537
Practice Address - Fax:860-350-9340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0938152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0719110001Medicare NSC