Provider Demographics
NPI:1386861326
Name:CHATHAM OPTOMETRIC OD PA
Entity Type:Organization
Organization Name:CHATHAM 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:919-933-6767
Mailing Address - Street 1:11312 US HIGHWAY 15-501 NORTH
Mailing Address - Street 2:STE 304
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-6376
Mailing Address - Country:US
Mailing Address - Phone:919-933-6767
Mailing Address - Fax:919-933-6732
Practice Address - Street 1:11312 US HIGHWAY 15-501 NORTH
Practice Address - Street 2:STE 304
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-6376
Practice Address - Country:US
Practice Address - Phone:919-933-6767
Practice Address - Fax:919-933-6732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790136LMedicaid
NC8909104Medicaid
NC4480650001OtherMEDICARE PTAN
NC152W00000XOtherTAXONOMY NUMBER
4480650001Medicare NSC
NC790136LMedicaid
NCU54004Medicare UPIN
NC8909104Medicaid