Provider Demographics
NPI:1851454151
Name:DOWNTOWN CLINIC OF OPTOMETRY, INC
Entity Type:Organization
Organization Name:DOWNTOWN CLINIC OF OPTOMETRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MORIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIYAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:314-231-0581
Mailing Address - Street 1:720 OLIVE ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63101-2338
Mailing Address - Country:US
Mailing Address - Phone:314-231-0581
Mailing Address - Fax:314-231-2690
Practice Address - Street 1:720 OLIVE ST
Practice Address - Street 2:SUITE 420
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-2338
Practice Address - Country:US
Practice Address - Phone:314-231-0581
Practice Address - Fax:314-231-2690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT2320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0791940001OtherMEDICARE REGIOND/DMERC
MO310753819Medicaid
MO000007673OtherMEDICARE PTAN
MO310753819Medicaid
MOT42717Medicare UPIN