Healthcare Provider Details

I. General information

NPI: 1770582108
Provider Name (Legal Business Name): ELINA BLAHA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12407 JEFFERSON AVE SUITE A
NEWPORT NEWS VA
23602-4311
US

IV. Provider business mailing address

PO BOX 14292
NEWPORT NEWS VA
23608-0006
US

V. Phone/Fax

Practice location:
  • Phone: 757-988-8903
  • Fax: 757-988-8903
Mailing address:
  • Phone: 757-988-8903
  • Fax: 757-988-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0601800141
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: