Healthcare Provider Details

I. General information

NPI: 1801004593
Provider Name (Legal Business Name): KENNETH E ANSELMI MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5433 GOVERNOR G C PEERY HWY
DORAN VA
24612
US

IV. Provider business mailing address

PO BOX 263
DORAN VA
24612
US

V. Phone/Fax

Practice location:
  • Phone: 276-963-0895
  • Fax: 276-963-5712
Mailing address:
  • Phone: 276-963-0895
  • Fax: 276-963-5712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH E ANSELMI
Title or Position: OWNER
Credential: MD
Phone: 276-963-0895