Provider Demographics
NPI:1891871299
Name:J DAVID AYCOCK, OD PA
Entity Type:Organization
Organization Name:J DAVID AYCOCK, OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COURTNAY
Authorized Official - Middle Name:
Authorized Official - Last Name:AYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-283-2179
Mailing Address - Street 1:808 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-3800
Mailing Address - Country:US
Mailing Address - Phone:704-283-2179
Mailing Address - Fax:704-283-8314
Practice Address - Street 1:808 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-3800
Practice Address - Country:US
Practice Address - Phone:704-283-2179
Practice Address - Fax:704-283-8314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890901AMedicaid
U52201Medicare UPIN
NC890901AMedicaid