Provider Demographics
NPI:1548311640
Name:MODERN EYES, LLC
Entity type:Organization
Organization Name:MODERN EYES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:BORSUK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:240-631-2255
Mailing Address - Street 1:108 OLDE TOWNE AVE
Mailing Address - Street 2:STE. 16
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2095
Mailing Address - Country:US
Mailing Address - Phone:240-631-2255
Mailing Address - Fax:
Practice Address - Street 1:108 OLDE TOWNE AVE
Practice Address - Street 2:STE. 16
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2095
Practice Address - Country:US
Practice Address - Phone:240-631-2255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1522152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG01801Medicare PIN