=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487899928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. ALEXANDER C. NNABUE & ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2008
-----------------------------------------------------
Last Update Date | 12/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10228 LAKE ARBOR WAY
-----------------------------------------------------
City | MITCHELLVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20721-3113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-324-9500
-----------------------------------------------------
Fax | 301-324-9502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 317 HAVILAND MILL RD
-----------------------------------------------------
City | BROOKEVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20833-2312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-325-9500
-----------------------------------------------------
Fax | 301-325-9502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | DR. PATRICIA PARKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-231-4086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | TA1277
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WL0500X
-----------------------------------------------------
Taxonomy Name | Low Vision Rehabilitation Optometrist
-----------------------------------------------------
License Number | TA1277
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number | TA1277
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152WS0006X
-----------------------------------------------------
Taxonomy Name | Sports Vision Optometrist
-----------------------------------------------------
License Number | TA1277
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TA1277
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------