Provider Demographics
NPI:1639179112
Name:BARENBURG OPTICAL SERVICE, INC
Entity Type:Organization
Organization Name:BARENBURG OPTICAL SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-752-1677
Mailing Address - Street 1:100 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-3416
Mailing Address - Country:US
Mailing Address - Phone:410-752-1677
Mailing Address - Fax:410-752-4435
Practice Address - Street 1:100 PARK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-3416
Practice Address - Country:US
Practice Address - Phone:410-752-1677
Practice Address - Fax:410-752-4435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4091880004Medicare NSC
MD693LMedicare PIN