Provider Demographics
NPI:1801851704
Name:CHRISTENBURY EYE CENTER P.A.
Entity Type:Organization
Organization Name:CHRISTENBURY EYE CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHRISTENBURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-332-9365
Mailing Address - Street 1:3621 RANDOLPH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1317
Mailing Address - Country:US
Mailing Address - Phone:704-332-9365
Mailing Address - Fax:704-364-7384
Practice Address - Street 1:3621 RANDOLPH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1317
Practice Address - Country:US
Practice Address - Phone:704-332-9365
Practice Address - Fax:704-364-7384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC57056152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0286VOtherBCBS/NC
NC7085246OtherAETNA
NC890286VMedicaid
NCCH5913Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE OD'S
NCCG3085Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE MD'S
NC0286VOtherBCBS/NC
NC2471646Medicare ID - Type UnspecifiedOD NUMBER
NC0938570001Medicare NSC