Healthcare Provider Details

I. General information

NPI: 1255579801
Provider Name (Legal Business Name): STEVEN LADERBERG OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5308 PROVIDENCE RD
VIRGINIA BEACH VA
23464-4102
US

IV. Provider business mailing address

5254 JACOB CT
VIRGINIA BEACH VA
23464-2518
US

V. Phone/Fax

Practice location:
  • Phone: 757-499-2020
  • Fax:
Mailing address:
  • Phone: 757-499-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000078
License Number StateVA

VIII. Authorized Official

Name: DR. STEVEN LADERBERG
Title or Position: OWNER
Credential: OD
Phone: 757-499-2020