Provider Demographics
NPI:1679853402
Name:MONTGOMERY VILLAGE EYECARE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:MONTGOMERY VILLAGE EYECARE ASSOCIATES, INC.
Other - Org Name:DR. MATTHEW E. BRODAK & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BRODAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:301-330-4265
Mailing Address - Street 1:9673 LOST KNIFE RD
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2622
Mailing Address - Country:US
Mailing Address - Phone:301-330-4265
Mailing Address - Fax:
Practice Address - Street 1:9673 LOST KNIFE RD
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2622
Practice Address - Country:US
Practice Address - Phone:301-330-4265
Practice Address - Fax:301-963-4508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1115152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U39252Medicare UPIN