Healthcare Provider Details

I. General information

NPI: 1245469964
Provider Name (Legal Business Name): TIDEWATER EYE CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 ACADEMY AVE SUITE 200
PORTSMOUTH VA
23703-3200
US

IV. Provider business mailing address

1564 LASKIN RD SUITE 192
VIRGINIA BEACH VA
23451-6187
US

V. Phone/Fax

Practice location:
  • Phone: 757-483-0400
  • Fax: 757-673-6832
Mailing address:
  • Phone: 757-483-0400
  • Fax: 757-422-6246

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. JONATHAN WEST
Title or Position: CEO
Credential:
Phone: 757-483-0400