Healthcare Provider Details

I. General information

NPI: 1982104105
Provider Name (Legal Business Name): D & G EYE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 MITCHELLS CHANCE RD STE 120
EDGEWATER MD
21037-2793
US

IV. Provider business mailing address

137 MITCHELLS CHANCE RD STE 120
EDGEWATER MD
21037-2793
US

V. Phone/Fax

Practice location:
  • Phone: 410-956-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTA2312
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberTA2312
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2312
License Number StateMD

VIII. Authorized Official

Name: AIDIN DEAN GOGERDCHI
Title or Position: OWNER
Credential: OD
Phone: 410-562-6636