Provider Demographics
NPI:1538323159
Name:EYEMAX
Entity Type:Organization
Organization Name:EYEMAX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TADELE
Authorized Official - Middle Name:
Authorized Official - Last Name:JEMBERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-476-0099
Mailing Address - Street 1:2211 METZEROTT RD
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-1623
Mailing Address - Country:US
Mailing Address - Phone:240-476-0099
Mailing Address - Fax:
Practice Address - Street 1:2211 METZEROTT RD
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-1623
Practice Address - Country:US
Practice Address - Phone:240-476-0099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-13
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD11483207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0368715 00Medicaid
DC0368715 00Medicaid