Provider Demographics
NPI:1124330535
Name:MIDWAY OPTOMETRIC EYE CARE, P.A.
Entity type:Organization
Organization Name:MIDWAY OPTOMETRIC EYE CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SASSER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-764-2449
Mailing Address - Street 1:11362 OLD US HIGHWAY 52
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-9841
Mailing Address - Country:US
Mailing Address - Phone:336-764-2449
Mailing Address - Fax:336-764-4156
Practice Address - Street 1:11362 OLD US HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9841
Practice Address - Country:US
Practice Address - Phone:336-764-2449
Practice Address - Fax:336-764-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0827850001OtherDMERC/PALMETTO
NC8909807Medicaid
NCT64937Medicare UPIN
0827850001OtherDMERC/PALMETTO