Provider Demographics
NPI:1518091131
Name:PENINSULA EYE CENTER, P.A.
Entity Type:Organization
Organization Name:PENINSULA EYE CENTER, P.A.
Other - Org Name:PENINSULA EYE SURGEONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LUPPENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-641-3955
Mailing Address - Street 1:101 MILFORD ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-6952
Mailing Address - Country:US
Mailing Address - Phone:410-749-9290
Mailing Address - Fax:410-543-9087
Practice Address - Street 1:314 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1215
Practice Address - Country:US
Practice Address - Phone:410-641-3955
Practice Address - Fax:410-641-9041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0022099332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
44435OtherDAVIS VISION
MDH788PEOtherCAREFIRST BLUE SHIELD
44435OtherDAVIS VISION