Provider Demographics
NPI:1194802199
Name:GREATER NORTH EAST EYE CARE CTN
Entity type:Organization
Organization Name:GREATER NORTH EAST EYE CARE CTN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:DOTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-396-8200
Mailing Address - Street 1:1647 BENNING RD NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002
Mailing Address - Country:US
Mailing Address - Phone:202-396-8200
Mailing Address - Fax:202-396-5023
Practice Address - Street 1:1647 BENNING RD NE
Practice Address - Street 2:SUITE 102
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002
Practice Address - Country:US
Practice Address - Phone:202-396-8200
Practice Address - Fax:202-396-5023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD20905207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F93082Medicare UPIN
BB553521Medicare ID - Type Unspecified