Provider Demographics
NPI:1306978069
Name:ASHEBORO OPTOMETRIC VISION PA
Entity type:Organization
Organization Name:ASHEBORO OPTOMETRIC VISION PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:V
Authorized Official - Credentials:OD
Authorized Official - Phone:336-625-2429
Mailing Address - Street 1:177 NC HIGHWAY 42 N STE B
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-7955
Mailing Address - Country:US
Mailing Address - Phone:336-625-2429
Mailing Address - Fax:336-625-9901
Practice Address - Street 1:177 NC HIGHWAY 42 N STE B
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-7955
Practice Address - Country:US
Practice Address - Phone:336-625-2429
Practice Address - Fax:336-625-9901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1962684605OtherINDIVIDUAL MEDICARE NPI
NC09778OtherBCBS
NC8909778Medicaid
NC09778OtherBCBS