Provider Demographics
NPI:1861777161
Name:PARKSIDE EYE CLINIC P.C.
Entity type:Organization
Organization Name:PARKSIDE EYE CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GHULAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DASTGIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-787-8443
Mailing Address - Street 1:2108 FOURTH STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-4518
Mailing Address - Country:US
Mailing Address - Phone:517-787-8443
Mailing Address - Fax:517-787-0701
Practice Address - Street 1:2108 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-4518
Practice Address - Country:US
Practice Address - Phone:517-787-8443
Practice Address - Fax:517-787-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036386207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty