Healthcare Provider Details

I. General information

NPI: 1548311640
Provider Name (Legal Business Name): MODERN EYES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 OLDE TOWNE AVE STE. 16
GAITHERSBURG MD
20877-2095
US

IV. Provider business mailing address

108 OLDE TOWNE AVE STE. 16
GAITHERSBURG MD
20877-2095
US

V. Phone/Fax

Practice location:
  • Phone: 240-631-2255
  • Fax:
Mailing address:
  • Phone: 240-631-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1522
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberTA1522
License Number StateMD

VIII. Authorized Official

Name: DR. MARK P BORSUK
Title or Position: OWNER
Credential: O.D.
Phone: 240-631-2255