Healthcare Provider Details

I. General information

NPI: 1417594656
Provider Name (Legal Business Name): SUMMIT EYE CARE OF MOCKSVILLE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102C YADKINVILLE RD
MOCKSVILLE NC
27028-2037
US

IV. Provider business mailing address

1102C YADKINVILLE RD
MOCKSVILLE NC
27028-2037
US

V. Phone/Fax

Practice location:
  • Phone: 336-751-5734
  • Fax: 336-751-4968
Mailing address:
  • Phone: 336-751-5734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: VICKAS KHEMSARA
Title or Position: OWNER
Credential: MD
Phone: 336-765-0960