Provider Demographics
NPI:1952630055
Name:PROFFITT EYE ASSOCIATES LLC
Entity Type:Organization
Organization Name:PROFFITT EYE ASSOCIATES LLC
Other - Org Name:PROFFITT EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-382-1781
Mailing Address - Street 1:711 N CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4311
Mailing Address - Country:US
Mailing Address - Phone:308-382-1781
Mailing Address - Fax:308-382-1474
Practice Address - Street 1:711 N CUSTER AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4311
Practice Address - Country:US
Practice Address - Phone:308-382-1781
Practice Address - Fax:308-382-1474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10-025813800Medicaid
NENA1514Medicare PIN