Provider Demographics
NPI:1508155813
Name:GOODWIN EYE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:GOODWIN EYE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF COMPANY
Authorized Official - Prefix:DR
Authorized Official - First Name:LILA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:301-341-6753
Mailing Address - Street 1:2400 FIVE LEES LN
Mailing Address - Street 2:OPTICAL DEPARTMENT
Mailing Address - City:GLENARDEN
Mailing Address - State:MD
Mailing Address - Zip Code:20706-1617
Mailing Address - Country:US
Mailing Address - Phone:301-341-6753
Mailing Address - Fax:301-341-6754
Practice Address - Street 1:2400 FIVE LEES LN
Practice Address - Street 2:OPTICAL DEPARTMENT
Practice Address - City:GLENARDEN
Practice Address - State:MD
Practice Address - Zip Code:20706-1617
Practice Address - Country:US
Practice Address - Phone:301-341-6753
Practice Address - Fax:301-341-6754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty