Healthcare Provider Details

I. General information

NPI: 1346488343
Provider Name (Legal Business Name): MID ATLANTIC EYE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 YORK RD STE 500
TOWSON MD
21204-5243
US

IV. Provider business mailing address

40 YORK RD STE 500
TOWSON MD
21204-5243
US

V. Phone/Fax

Practice location:
  • Phone: 410-616-9952
  • Fax: 443-927-7515
Mailing address:
  • Phone: 410-616-9952
  • Fax: 443-927-7515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0067362
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SUDEEP PRAMANIK
Title or Position: PRESIDENT
Credential: MD, MBA
Phone: 410-616-9952