MEDICARE: KULSOOM T. MURTAZA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0618001931	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	KM003908	OTHER	MI	STATE LICENSE NUMBER
2	900C363570	OTHER	MI	BLUE CROSS BLUE SHIELD
3	200000002790	OTHER	MI	PHPMM
4	0618001931	OTHER	VA	STATE LICENSE

General Provider Information

NPI Number	:	1639181472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KULSOOM T. MURTAZA OD

Provider Business Mailing Address
First Line	:	400 WESTHAMPTON STA
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23226-3330
Country	:	US
Telephone Number	:	804-287-4200
Fax Number	:	804-287-4210

Provider Business Practice Location Address
First Line	:	2015 WATERSIDE RD
Second Line	:
City	:	PRINCE GEORGE
State	:	VA
Zip	:	23875-1265
Country	:	US
Telephone Number	:	804-733-7300
Fax Number	:	804-733-7390

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	02/14/2012

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