Healthcare Provider Details

I. General information

NPI: 1962401612
Provider Name (Legal Business Name): MICHAEL RAYMOND KEVERLINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL RAYMOND KEVERLINE MD

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3206 CHURCHLAND BLVD
CHESAPEAKE VA
23321-5206
US

IV. Provider business mailing address

3206 CHURCHLAND BLVD
CHESAPEAKE VA
23321-5206
US

V. Phone/Fax

Practice location:
  • Phone: 757-484-0101
  • Fax: 757-484-0515
Mailing address:
  • Phone: 757-484-0101
  • Fax: 757-484-0515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101230614
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number7010360
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: