Provider Demographics
NPI:1275505117
Name:MJB OPTICAL, INC.
Entity Type:Organization
Organization Name:MJB OPTICAL, INC.
Other - Org Name:MAIN STREET EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-248-3937
Mailing Address - Street 1:3201 HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6578
Mailing Address - Country:US
Mailing Address - Phone:573-248-3937
Mailing Address - Fax:573-221-4393
Practice Address - Street 1:3201 HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6578
Practice Address - Country:US
Practice Address - Phone:573-248-3937
Practice Address - Fax:573-221-4393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-05
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5478320001Medicare NSC
MO000014650Medicare PIN