Provider Demographics
NPI:1942376645
Name:EYE CENTER OF SOUTHERN CONNECTICUT, P.C.
Entity Type:Organization
Organization Name:EYE CENTER OF SOUTHERN CONNECTICUT, P.C.
Other - Org Name:EYE CENTER OPTICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MASI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-248-6365
Mailing Address - Street 1:2880 OLD DIXWELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3144
Mailing Address - Country:US
Mailing Address - Phone:203-248-6365
Mailing Address - Fax:203-281-2742
Practice Address - Street 1:249 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405
Practice Address - Country:US
Practice Address - Phone:203-483-2000
Practice Address - Fax:203-483-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT332B00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0674910003OtherPTAN
CT004067435Medicaid