Organization
BETHESDA EYE CENTER, OPTOMETRY, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. J GRADY ELLIOTT O.D. (PRESIDENT)
(336) 765-8130
Entity
Organization
Contact information
Practice address
3111 MAPLEWOOD AVE, SUITE 103, WINSTON SALEM, NC 27103-3906
(336) 765-8130
(336) 765-6403
Mailing address
3111 MAPLEWOOD AVE, SUITE 103, WINSTON SALEM, NC 27103-3906
(336) 765-8130
(336) 765-6403
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1456
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2468143
MEDICARE - PTAN
NC
05
—
8801962
—
NC
Enumeration date
02/08/2007
Last updated
05/16/2011
Update your record
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