Provider Demographics
NPI:1518007491
Name:BETHESDA EYE CENTER, OPTOMETRY, PA
Entity Type:Organization
Organization Name:BETHESDA EYE CENTER, OPTOMETRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J GRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-765-8130
Mailing Address - Street 1:3111 MAPLEWOOD AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3906
Mailing Address - Country:US
Mailing Address - Phone:336-765-8130
Mailing Address - Fax:336-765-6403
Practice Address - Street 1:3111 MAPLEWOOD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3906
Practice Address - Country:US
Practice Address - Phone:336-765-8130
Practice Address - Fax:336-765-6403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1456152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2468143OtherMEDICARE - PTAN
NC8801962Medicaid
NC2468143OtherMEDICARE - PTAN