Healthcare Provider Details

I. General information

NPI: 1124485503
Provider Name (Legal Business Name): SANDRA VIDACIC MOKRIS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA VIDACIC OD

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6136 FALLS OF NEUSE RD
RALEIGH NC
27609-3528
US

IV. Provider business mailing address

6136 FALLS OF NEUSE RD
RALEIGH NC
27609-3528
US

V. Phone/Fax

Practice location:
  • Phone: 984-206-6890
  • Fax:
Mailing address:
  • Phone: 984-206-6890
  • Fax: 984-307-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2541
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: