Provider Demographics
NPI:1396747879
Name:GONTAREK OPTOMETRIC CONSULTANTS, LLC
Entity type:Organization
Organization Name:GONTAREK OPTOMETRIC CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GONTAREK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-966-2206
Mailing Address - Street 1:1508 ODMAN DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-1874
Mailing Address - Country:US
Mailing Address - Phone:757-488-7066
Mailing Address - Fax:757-488-2300
Practice Address - Street 1:2448 CHESAPEAKE SQUARE RING RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2173
Practice Address - Country:US
Practice Address - Phone:757-488-7066
Practice Address - Fax:757-488-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-13
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08648Medicare ID - Type Unspecified