Provider Demographics
NPI:1063690485
Name:OPTIC IVY
Entity type:Organization
Organization Name:OPTIC IVY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PNINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:410-857-3734
Mailing Address - Street 1:405 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5119
Mailing Address - Country:US
Mailing Address - Phone:410-857-3734
Mailing Address - Fax:410-857-9043
Practice Address - Street 1:405 N CENTER ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5119
Practice Address - Country:US
Practice Address - Phone:410-857-3734
Practice Address - Fax:410-857-9043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1836152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU97900Medicare UPIN
MD793MMedicare PIN