Provider Demographics
NPI:1295829380
Name:CHARLOTTE OPTOMETRY GROUP PA
Entity Type:Organization
Organization Name:CHARLOTTE OPTOMETRY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-510-0816
Mailing Address - Street 1:8701 JW CLAY BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-5417
Mailing Address - Country:US
Mailing Address - Phone:704-510-0816
Mailing Address - Fax:704-510-0919
Practice Address - Street 1:8701 JW CLAY BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5417
Practice Address - Country:US
Practice Address - Phone:704-510-0816
Practice Address - Fax:704-510-0919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8381680OtherAETNA
NC890143TMedicaid
0143TOtherBC/BS NC
2467814AMedicare ID - Type Unspecified