Provider Demographics
NPI:1952595084
Name:VISIONARY OPHTHALMOLOGY LLC
Entity Type:Organization
Organization Name:VISIONARY OPHTHALMOLOGY LLC
Other - Org Name:VISIONARY EYE DOCTORS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:J.ALBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-896-0890
Mailing Address - Street 1:11300 ROCKVILLE PIKE STE 1202
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3040
Mailing Address - Country:US
Mailing Address - Phone:301-896-0890
Mailing Address - Fax:301-896-0968
Practice Address - Street 1:11300 ROCKVILLE PIKE STE 1202
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3040
Practice Address - Country:US
Practice Address - Phone:301-896-0890
Practice Address - Fax:301-896-0968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0041347174400000X
207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC68078400Medicaid
MD4590040Medicaid
MD4590040Medicaid