Provider Demographics
NPI:1396817367
Name:OPTOMETRIC ASSOCIATES OF CEDAR RAPIDS,P.C.
Entity Type:Organization
Organization Name:OPTOMETRIC ASSOCIATES OF CEDAR RAPIDS,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIVIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:319-365-8621
Mailing Address - Street 1:860 2ND AVE SE
Mailing Address - Street 2:STE. B
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2460
Mailing Address - Country:US
Mailing Address - Phone:319-365-8621
Mailing Address - Fax:319-365-9500
Practice Address - Street 1:860 2ND AVE SE
Practice Address - Street 2:STE. B
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2460
Practice Address - Country:US
Practice Address - Phone:319-365-8621
Practice Address - Fax:319-365-9500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA07579OtherBLUE CROSS,BLUE SHIELD
IA0075796Medicaid
IA07579Medicare ID - Type Unspecified
IA07579OtherBLUE CROSS,BLUE SHIELD