NPIMap

Organization Active NPI

Custom Eyes Optical

  • Optometrist
  • Reisterstown, MD
National Provider Identifier
1720292865
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
TA0666 Issued in MD
Legal business name
CUSTOM EYES OPTICAL
Practice address
11977 Reisterstown Rd
Reisterstown, MD 21136-3030
Phone
(410) 833-1910
Fax
(410) 833-1911
NPI assigned
May 9, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Fred Havelock, OPTN
Title
Pres
Phone
(410) 833-1910

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X TA0666 MD Primary

Addresses

Primary practice location

11977 Reisterstown Rd
Reisterstown, MD 21136-3030

Mailing address

11977 Reisterstown Rd
Reisterstown, MD 21136-3030
Phone (410) 833-1910

National Provider Directory

National Provider Directory

Locations

11977 Reisterstown Rd
Reisterstown, MD 21136
Phone (410) 833-1910

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178668800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1720292865",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11977 REISTERSTOWN RD",
            "city": "REISTERSTOWN",
            "state": "MD",
            "postal_code": "211363030",
            "telephone_number": "410-833-1910",
            "fax_number": "410-833-1911"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11977 REISTERSTOWN RD",
            "city": "REISTERSTOWN",
            "state": "MD",
            "postal_code": "211363030",
            "telephone_number": "410-833-1910",
            "fax_number": "410-833-1911"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CUSTOM EYES OPTICAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-09",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "HAVELOCK",
        "authorized_official_first_name": "FRED",
        "authorized_official_title_or_position": "PRES",
        "authorized_official_telephone_number": "410-833-1910",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "OPTN"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "MD",
            "license": "TA0666",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Reisterstown, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.