Provider Demographics
NPI:1508136029
Name:MARYLAND EYE PHYSICIAN AND SURGEON, LLC
Entity Type:Organization
Organization Name:MARYLAND EYE PHYSICIAN AND SURGEON, LLC
Other - Org Name:MARYLAND EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-671-3808
Mailing Address - Street 1:11217 KORMAN DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2049
Mailing Address - Country:US
Mailing Address - Phone:240-671-3808
Mailing Address - Fax:240-232-2016
Practice Address - Street 1:2403 RESEARCH BLVD STE 102
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6233
Practice Address - Country:US
Practice Address - Phone:240-671-3808
Practice Address - Fax:240-232-2016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-02
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061666207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD331604100Medicaid
MD405809700Medicaid
MD243873Medicare PIN
MD243875Medicare PIN
DC178540YGP3Medicare PIN
MD331604100Medicaid