Provider Demographics
NPI:1447462643
Name:WAKE OPHTHALMOLOGY ASSOCIATES, PA
Entity type:Organization
Organization Name:WAKE OPHTHALMOLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:ROBERTSON
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-467-4500
Mailing Address - Street 1:105 SW CARY PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-5600
Mailing Address - Country:US
Mailing Address - Phone:919-467-4500
Mailing Address - Fax:919-460-9339
Practice Address - Street 1:105 SW CARY PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-5600
Practice Address - Country:US
Practice Address - Phone:919-467-4500
Practice Address - Fax:919-460-9339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26998174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985736Medicaid
NC85736OtherBCBS
NC85736OtherBCBS