Provider Demographics
NPI:1487864062
Name:CHESAPEAKE BAY OPTICAL
Entity Type:Organization
Organization Name:CHESAPEAKE BAY OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:COCKRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-841-1909
Mailing Address - Street 1:2003 MEDICAL PARKWAY
Mailing Address - Street 2:SUITE G90
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401
Mailing Address - Country:US
Mailing Address - Phone:410-841-1909
Mailing Address - Fax:410-571-8624
Practice Address - Street 1:2003 MEDICAL PKWY
Practice Address - Street 2:SUITE G90
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7992
Practice Address - Country:US
Practice Address - Phone:410-841-1909
Practice Address - Fax:410-571-8624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02207819332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD02207819OtherSTATE LICENSE
MDXY29CHOtherBLUE SHIELD
MDXY29CHOtherBLUE SHIELD