MEDICARE: OPTICAL OPHTHAMIC ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1142680002	OTHER	NV	MC DME SUPPLIER NUMBER

General Provider Information

NPI Number	:	1043347552
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL OPHTHAMIC ASSOCIATES

Provider Business Mailing Address
First Line	:	3016 W CHARLESTON BLVD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1977
Country	:	US
Telephone Number	:	702-870-2020
Fax Number	:	702-870-3429

Provider Business Practice Location Address
First Line	:	3016 W CHARLESTON BLVD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1977
Country	:	US
Telephone Number	:	702-870-2020
Fax Number	:	702-870-3429

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MISS BOBBETTE A. SMITH
Credential	:
Telephone Number	:	702-870-2020

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	08/22/2020

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