MEDICARE: MIDWAY OPTOMETRIC EYE CARE, P.A.

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	152W00000X	Optometrist	1090	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0827850001	OTHER		DMERC/PALMETTO
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124330535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWAY OPTOMETRIC EYE CARE, P.A.

Provider Business Mailing Address
First Line	:	11362 OLD US HIGHWAY 52
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27107-9841
Country	:	US
Telephone Number	:	336-764-2449
Fax Number	:	336-764-4156

Provider Business Practice Location Address
First Line	:	11362 OLD US HIGHWAY 52
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27107-9841
Country	:	US
Telephone Number	:	336-764-2449
Fax Number	:	336-764-4156

Authorized Official
Title or Position	:	OWNER
Name	:	CARL DAVID SASSER
Credential	:	OD
Telephone Number	:	336-764-2449

Provider Enumeration Date	:	07/14/2010
Last Update Date	:	07/30/2010

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