=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538244975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKWOOD EYE CENTER, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 S. GRAYSON STREET
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-835-3400
-----------------------------------------------------
Fax | 336-835-3664
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 177 PARKWOOD DR
-----------------------------------------------------
City | ELKIN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28621-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-835-3400
-----------------------------------------------------
Fax | 336-835-3664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. SUSAN STEWART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-835-3400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------