Healthcare Provider Details

I. General information

NPI: 1598197501
Provider Name (Legal Business Name): REBECCA DAWN BUMGARDNER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3332 PRINCESS ANNE RD SUITE 611
VIRGINIA BEACH VA
23456-2613
US

IV. Provider business mailing address

3332 PRINCESS ANNE RD SUITE 611
VIRGINIA BEACH VA
23456-2613
US

V. Phone/Fax

Practice location:
  • Phone: 757-368-2828
  • Fax:
Mailing address:
  • Phone: 757-368-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1761
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002245
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: