Healthcare Provider Details

I. General information

NPI: 1164177838
Provider Name (Legal Business Name): GATEWAY VISION CARE, OD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13520 NC HIGHWAY 50
SURF CITY NC
28445-6554
US

IV. Provider business mailing address

PO BOX 2429
SURF CITY NC
28445-0027
US

V. Phone/Fax

Practice location:
  • Phone: 910-803-0556
  • Fax:
Mailing address:
  • Phone: 910-803-0556
  • Fax: 910-338-3160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. PHILLIP TART
Title or Position: PRESIDENT
Credential: OD
Phone: 910-520-9130