Provider Demographics
NPI:1952567026
Name:LAKEVILLE EYE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:LAKEVILLE EYE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:KIRBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:8604-335-0072
Mailing Address - Street 1:31 PORTER ST
Mailing Address - Street 2:PO BOX 548
Mailing Address - City:LAKEVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06039-1214
Mailing Address - Country:US
Mailing Address - Phone:860-435-0072
Mailing Address - Fax:860-435-9831
Practice Address - Street 1:31 PORTER ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:CT
Practice Address - Zip Code:06039-1214
Practice Address - Country:US
Practice Address - Phone:860-435-0072
Practice Address - Fax:860-435-9831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023349207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D100000086OtherMEDICARE PTAN