Provider Demographics
NPI:1194914333
Name:POTOMAC EYE SURGEONS PA
Entity type:Organization
Organization Name:POTOMAC EYE SURGEONS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:WENGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-299-5666
Mailing Address - Street 1:11500 LAKE POTOMAC DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1223
Mailing Address - Country:US
Mailing Address - Phone:301-299-5666
Mailing Address - Fax:301-299-6021
Practice Address - Street 1:11500 LAKE POTOMAC DR
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-1223
Practice Address - Country:US
Practice Address - Phone:301-299-5666
Practice Address - Fax:301-299-6021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207W00000X
MD261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCX51217Medicare UPIN
DCG00394Medicare PIN