Provider Demographics
NPI:1407261498
Name:SURGICAL AND MEDICAL OPHTHAMOLOGY LLC
Entity Type:Organization
Organization Name:SURGICAL AND MEDICAL OPHTHAMOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-646-4083
Mailing Address - Street 1:295 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5211
Mailing Address - Country:US
Mailing Address - Phone:860-646-4083
Mailing Address - Fax:860-647-1733
Practice Address - Street 1:295 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5211
Practice Address - Country:US
Practice Address - Phone:860-646-4083
Practice Address - Fax:860-647-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027201207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001272012Medicaid
CT180000882Medicare PIN
CTD02567Medicare UPIN