Provider Demographics
NPI:1851580807
Name:QUEEN CITY OPHTHALMOLOGY
Entity Type:Organization
Organization Name:QUEEN CITY OPHTHALMOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDYE
Authorized Official - Middle Name:C
Authorized Official - Last Name:VANBRAKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-722-2050
Mailing Address - Street 1:625 KENT AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-3794
Mailing Address - Country:US
Mailing Address - Phone:301-722-2050
Mailing Address - Fax:301-722-2072
Practice Address - Street 1:625 KENT AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-3794
Practice Address - Country:US
Practice Address - Phone:301-722-2050
Practice Address - Fax:301-722-2072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD41403207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD369MMedicare PIN
MDB39883Medicare UPIN