MEDICARE: UNIVERSITY EYE ASSOCIATES, OD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	09040	OTHER	NC	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1205893435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY EYE ASSOCIATES, OD PA

Provider Business Mailing Address
First Line	:	9651 BROOKDALE DR.
Second Line	:	SUITE 800
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-8105
Country	:	US
Telephone Number	:	704-536-6042
Fax Number	:	704-563-5917

Provider Business Practice Location Address
First Line	:	9651 BROOKDALE DR.
Second Line	:	SUITE 800
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-8105
Country	:	US
Telephone Number	:	704-536-6042
Fax Number	:	704-563-5917

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. KELLY ALEXANDER
Credential	:
Telephone Number	:	704-547-1551

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	06/29/2012

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