Provider Demographics
NPI:1710958301
Name:MIDWEST OPTOMETRIC ASSOCIATES PC
Entity Type:Organization
Organization Name:MIDWEST OPTOMETRIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:AHERN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:563-875-8123
Mailing Address - Street 1:420 1ST AVE E
Mailing Address - Street 2:PO BOX 160
Mailing Address - City:DYERSVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52040-1326
Mailing Address - Country:US
Mailing Address - Phone:563-875-8123
Mailing Address - Fax:563-875-7874
Practice Address - Street 1:420 1ST AVE E
Practice Address - Street 2:
Practice Address - City:DYERSVILLE
Practice Address - State:IA
Practice Address - Zip Code:52040-1326
Practice Address - Country:US
Practice Address - Phone:563-875-8123
Practice Address - Fax:563-875-7874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1609152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0144170Medicaid
IA0144170Medicaid
U10409Medicare UPIN
IA0433040001Medicare NSC