Provider Demographics
NPI:1427081199
Name:NORWICH OPHTHALMOLOGY OPTICAL
Entity type:Organization
Organization Name:NORWICH OPHTHALMOLOGY OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SEC
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:OAKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-886-0161
Mailing Address - Street 1:79 WAWECUS STREET
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360
Mailing Address - Country:US
Mailing Address - Phone:860-886-0161
Mailing Address - Fax:860-889-5999
Practice Address - Street 1:79 WAWECUS STREET
Practice Address - Street 2:SUITE 105
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360
Practice Address - Country:US
Practice Address - Phone:860-886-0161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT100000433CT03OtherBCS
CT008002781Medicaid
CTP2130727OtherOXFORD
CT100000433CT03OtherBCS