Provider Demographics
NPI:1912949785
Name:PLEASANT VALLEY OPHTHALMOLOGY, PLLC
Entity Type:Organization
Organization Name:PLEASANT VALLEY OPHTHALMOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-223-3937
Mailing Address - Street 1:11825 HINSON RD
Mailing Address - Street 2:STE. 103
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-3404
Mailing Address - Country:US
Mailing Address - Phone:501-223-3937
Mailing Address - Fax:501-223-8656
Practice Address - Street 1:11825 HINSON RD
Practice Address - Street 2:STE. 103
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-3404
Practice Address - Country:US
Practice Address - Phone:501-223-3937
Practice Address - Fax:501-223-8656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARCJ3133OtherRR MEDICARE GROUP #
ARCJ3133OtherRR MEDICARE GROUP #