Provider Demographics
NPI:1467520890
Name:MOUNTAINEER VISION CENTER, PLLC
Entity Type:Organization
Organization Name:MOUNTAINEER VISION CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-296-3333
Mailing Address - Street 1:827 FAIRMONT RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-3857
Mailing Address - Country:US
Mailing Address - Phone:304-296-3333
Mailing Address - Fax:304-296-2220
Practice Address - Street 1:827 FAIRMONT RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-3857
Practice Address - Country:US
Practice Address - Phone:304-296-3333
Practice Address - Fax:304-296-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV663-D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001261Medicaid
WV5439530001Medicare NSC
WV3810001261Medicaid