Provider Demographics
NPI:1992887731
Name:MONONGALIA EYE CLINIC LLC
Entity type:Organization
Organization Name:MONONGALIA EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:V
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-598-0055
Mailing Address - Street 1:3140 COLLINS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3352
Mailing Address - Country:US
Mailing Address - Phone:304-598-0055
Mailing Address - Fax:304-598-0058
Practice Address - Street 1:3140 COLLINS FERRY RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3352
Practice Address - Country:US
Practice Address - Phone:304-598-0055
Practice Address - Fax:304-598-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9313971Medicare PIN