Provider Demographics
NPI:1922094895
Name:MEDICAL EYE ASSOCIATES PA
Entity Type:Organization
Organization Name:MEDICAL EYE ASSOCIATES PA
Other - Org Name:WILSON OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PUTNAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-443-6129
Mailing Address - Street 1:1707 MEDICAL PARK DR W
Mailing Address - Street 2:STE1
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-2768
Mailing Address - Country:US
Mailing Address - Phone:252-291-7008
Mailing Address - Fax:252-291-1281
Practice Address - Street 1:1707 MEDICAL PARK DR W
Practice Address - Street 2:STE1
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2768
Practice Address - Country:US
Practice Address - Phone:252-291-7008
Practice Address - Fax:252-291-1281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
180044388OtherRR MEDICARE
180641778OtherRR MEDICARE
180041942OtherRR MEDICARE
1180LOtherBC
180041781OtherRR MEDICARE
NC1073659769OtherNPI JOHN E THORDSEN
22680OtherBC
190041779OtherRR MEDICARE
P00720248OtherRAILROAD MCEDICARE
37986OtherBC
1093VOtherBC
12630OtherBC
12630OtherBC
P00720248OtherRAILROAD MCEDICARE
180641778OtherRR MEDICARE
37986OtherBC
C79904Medicare UPIN
G06090Medicare UPIN