MEDICARE: DOCTORS VISION CENTER OD PA

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	017J2	OTHER	NC	BCBS GRP #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801844840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTORS VISION CENTER OD PA

Provider Business Mailing Address
First Line	:	335 N MAIN ST
Second Line	:
City	:	WALNUT COVE
State	:	NC
Zip	:	27052-9200
Country	:	US
Telephone Number	:	336-591-7428
Fax Number	:	336-591-5136

Provider Business Practice Location Address
First Line	:	335 N MAIN ST
Second Line	:
City	:	WALNUT COVE
State	:	NC
Zip	:	27052-9200
Country	:	US
Telephone Number	:	336-591-7428
Fax Number	:	336-591-5136

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	TINA M BURGESS
Credential	:
Telephone Number	:	252-442-0802

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	08/30/2011

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