Provider Demographics
NPI:1467538967
Name:MARTINSBURG EYE ASSOCIATES PLLC
Entity Type:Organization
Organization Name:MARTINSBURG EYE ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSEHOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-267-4273
Mailing Address - Street 1:2002 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-8808
Mailing Address - Country:US
Mailing Address - Phone:304-267-4273
Mailing Address - Fax:
Practice Address - Street 1:2002 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-8808
Practice Address - Country:US
Practice Address - Phone:304-267-4273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19369207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0202125000Medicaid
WV9310551Medicare PIN
WVG08579Medicare UPIN