Provider Demographics
NPI:1043347552
Name:OPTICAL OPHTHAMIC ASSOCIATES
Entity type:Organization
Organization Name:OPTICAL OPHTHAMIC ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:BOBBETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-870-2020
Mailing Address - Street 1:3016 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1977
Mailing Address - Country:US
Mailing Address - Phone:702-870-2020
Mailing Address - Fax:702-870-3429
Practice Address - Street 1:3016 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1977
Practice Address - Country:US
Practice Address - Phone:702-870-2020
Practice Address - Fax:702-870-3429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1142680002OtherMC DME SUPPLIER NUMBER