Provider Demographics
NPI:1467593582
Name:EAGLE EYE CARE, P.A.
Entity Type:Organization
Organization Name:EAGLE EYE CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:SIROTKIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-964-8516
Mailing Address - Street 1:6350 STEVENS FOREST RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-3231
Mailing Address - Country:US
Mailing Address - Phone:410-964-8516
Mailing Address - Fax:410-740-8626
Practice Address - Street 1:6350 STEVENS FOREST RD
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3231
Practice Address - Country:US
Practice Address - Phone:410-964-8516
Practice Address - Fax:410-740-8626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA 0870332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA115NMedicare PIN
MDU34883Medicare UPIN
MD5452550001Medicare NSC
MD115NMedicare PIN