Provider Demographics
NPI:1801987912
Name:GONTAREK EYE CARE OPTOMETRISTS LLC
Entity type:Organization
Organization Name:GONTAREK EYE CARE OPTOMETRISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:V
Authorized Official - Last Name:GONTAREK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-966-2206
Mailing Address - Street 1:501 BATTLEFIELD BLVD N
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4947
Mailing Address - Country:US
Mailing Address - Phone:757-966-2206
Mailing Address - Fax:757-966-2743
Practice Address - Street 1:501 BATTLEFIELD BLVD N
Practice Address - Street 2:SUITE B
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4947
Practice Address - Country:US
Practice Address - Phone:757-966-2206
Practice Address - Fax:757-966-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU68023Medicare UPIN
VAC08826Medicare PIN