Provider Demographics
NPI:1366966186
Name:IDEAL EYE SURGERY LLC
Entity type:Organization
Organization Name:IDEAL EYE SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:STOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-391-1660
Mailing Address - Street 1:1660 ESSEX WAY STE A
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3076
Mailing Address - Country:US
Mailing Address - Phone:618-391-1660
Mailing Address - Fax:617-275-2198
Practice Address - Street 1:1660 ESSEX WAY STE A
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3076
Practice Address - Country:US
Practice Address - Phone:618-391-1660
Practice Address - Fax:617-275-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016004847207W00000X
IL036.141217207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty