Provider Demographics
NPI:1689903965
Name:EYE CLINIC OF FAIRBANKS, INC
Entity Type:Organization
Organization Name:EYE CLINIC OF FAIRBANKS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ZAMBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-456-7760
Mailing Address - Street 1:116 MINNIE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3006
Mailing Address - Country:US
Mailing Address - Phone:907-456-7760
Mailing Address - Fax:907-451-7916
Practice Address - Street 1:116 MINNIE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3006
Practice Address - Country:US
Practice Address - Phone:907-456-7760
Practice Address - Fax:907-451-7916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK292621152W00000X, 156FX1800X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKA0330OtherBLUE CROSS
AKMDG576Medicaid
0000WCPCXMedicare PIN
AK0790210003Medicare NSC