Provider Demographics
NPI:1669648879
Name:EYE SURGICAL ASSOCIATES P C
Entity Type:Organization
Organization Name:EYE SURGICAL ASSOCIATES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-699-2244
Mailing Address - Street 1:2664 HARTFORD HWY
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4904
Mailing Address - Country:US
Mailing Address - Phone:334-699-2244
Mailing Address - Fax:334-699-2245
Practice Address - Street 1:2664 HARTFORD HWY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-4904
Practice Address - Country:US
Practice Address - Phone:334-699-2244
Practice Address - Fax:334-699-2245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13178207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty