=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831157866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY EYE ASSOCIATES OD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 08/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8316 MEDICAL PLAZA DR STE E
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-6704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-547-1551
-----------------------------------------------------
Fax | 704-548-8017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8316 MEDICAL PLAZA DR STE E
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-6704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-547-1551
-----------------------------------------------------
Fax | 704-548-8017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | DECEMBER SMITH JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-505-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------