Provider Demographics
NPI:1235526229
Name:INTRACOASTAL EYE, PLLC
Entity Type:Organization
Organization Name:INTRACOASTAL EYE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:M
Authorized Official - Phone:910-777-8254
Mailing Address - Street 1:6740 ROCK SPRING RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3186
Mailing Address - Country:US
Mailing Address - Phone:910-777-8254
Mailing Address - Fax:910-769-1246
Practice Address - Street 1:6740 ROCK SPRING RD STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405
Practice Address - Country:US
Practice Address - Phone:910-777-8254
Practice Address - Fax:910-769-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500742207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty