Provider Demographics
NPI:1922214634
Name:MERCEDES OPTICAL
Entity type:Organization
Organization Name:MERCEDES OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:BOONE
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-329-9666
Mailing Address - Street 1:3101 MERCEDES DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5153
Mailing Address - Country:US
Mailing Address - Phone:318-329-9666
Mailing Address - Fax:318-388-0000
Practice Address - Street 1:3101 MERCEDES DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5153
Practice Address - Country:US
Practice Address - Phone:318-329-9666
Practice Address - Fax:318-388-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1273330001Medicare NSC