Provider Demographics
NPI:1285635250
Name:THE EYE DOCTORS PC
Entity Type:Organization
Organization Name:THE EYE DOCTORS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:G
Authorized Official - Last Name:SIETSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-338-7104
Mailing Address - Street 1:5116 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2677
Mailing Address - Country:US
Mailing Address - Phone:605-338-7104
Mailing Address - Fax:605-575-3880
Practice Address - Street 1:5116 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2677
Practice Address - Country:US
Practice Address - Phone:605-338-7104
Practice Address - Fax:605-575-3880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD208152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI5913OtherRR MEDICARE
57D33THOtherBCBS OF MN
SD5760Medicare PIN
SD1238480001Medicare NSC