Provider Demographics
NPI:1851307953
Name:FLACK, JOHN ELLIS (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ELLIS
Last Name:FLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 E PARKER RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-5112
Mailing Address - Country:US
Mailing Address - Phone:828-433-1000
Mailing Address - Fax:828-433-6274
Practice Address - Street 1:335 E PARKER RD
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-5112
Practice Address - Country:US
Practice Address - Phone:828-433-1000
Practice Address - Fax:828-433-6274
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1291152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890927CMedicaid
NC0927COtherBLUE CROSS BLUE SHIELD NC
NC2467593KMedicare PIN
NC2467593HMedicare PIN
NC2467593GMedicare PIN
NC890927CMedicaid
NC0927COtherBLUE CROSS BLUE SHIELD NC
U17735Medicare UPIN