Provider Demographics
NPI:1205893435
Name:UNIVERSITY EYE ASSOCIATES, OD PA
Entity type:Organization
Organization Name:UNIVERSITY EYE ASSOCIATES, OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-547-1551
Mailing Address - Street 1:9651 BROOKDALE DR.
Mailing Address - Street 2:SUITE 800
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8105
Mailing Address - Country:US
Mailing Address - Phone:704-536-6042
Mailing Address - Fax:704-563-5917
Practice Address - Street 1:9651 BROOKDALE DR.
Practice Address - Street 2:SUITE 800
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-8105
Practice Address - Country:US
Practice Address - Phone:704-536-6042
Practice Address - Fax:704-563-5917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7909040Medicaid
NC09040OtherBLUE CROSS BLUE SHIELD
NC2468134Medicare PIN
NC09040OtherBLUE CROSS BLUE SHIELD