Provider Demographics
NPI:1386830701
Name:SANFORD OPTOMETRIC OD PA
Entity Type:Organization
Organization Name:SANFORD OPTOMETRIC OD PA
Other - Org Name:CAROLINA VISION ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-776-2032
Mailing Address - Street 1:1829 DOCTORS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-5067
Mailing Address - Country:US
Mailing Address - Phone:919-776-2032
Mailing Address - Fax:919-775-2179
Practice Address - Street 1:1829 DOCTORS DRIVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5067
Practice Address - Country:US
Practice Address - Phone:919-776-2032
Practice Address - Fax:919-775-2179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1551152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386830701Medicare NSC
6023580001Medicare NSC
NC6023580001Medicare NSC