Healthcare Provider Details

I. General information

NPI: 1174891295
Provider Name (Legal Business Name): BERNHARD J URBAN OPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2011
Last Update Date: 12/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12704 JEFFERSON DAVIS HWY
CHESTER VA
23831-5369
US

IV. Provider business mailing address

12704 JEFFERSON DAVIS HWY
CHESTER VA
23831-5369
US

V. Phone/Fax

Practice location:
  • Phone: 804-237-9195
  • Fax:
Mailing address:
  • Phone: 804-237-9195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1101002897
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: