Provider Demographics
NPI:1245347327
Name:PIEDMONT OPHTHALMOLOGY CLINIC INC
Entity type:Organization
Organization Name:PIEDMONT OPHTHALMOLOGY CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:H
Authorized Official - Last Name:GAMMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-799-3232
Mailing Address - Street 1:746 NE JENSEN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-4754
Mailing Address - Country:US
Mailing Address - Phone:434-250-6270
Mailing Address - Fax:
Practice Address - Street 1:746 NE JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4754
Practice Address - Country:US
Practice Address - Phone:434-250-6270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080168OtherBCBS ANTHEM
VA080168OtherBCBS ANTHEM