Provider Demographics
NPI:1255675740
Name:MASSIE OPTOMETRY PC
Entity Type:Organization
Organization Name:MASSIE OPTOMETRY PC
Other - Org Name:PERFORMANCE EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:F
Authorized Official - Last Name:MASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-234-3053
Mailing Address - Street 1:4111 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7609
Mailing Address - Country:US
Mailing Address - Phone:618-234-3053
Mailing Address - Fax:618-234-6331
Practice Address - Street 1:465 N NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6824
Practice Address - Country:US
Practice Address - Phone:314-878-1377
Practice Address - Fax:314-878-1384
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERFORMANCE EYECARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-21
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002005316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21178Medicare PIN
ILU87226Medicare UPIN