Healthcare Provider Details

I. General information

NPI: 1316954621
Provider Name (Legal Business Name): ROBERT EDWARD TITCOMB OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 INDEPENDENCE BLVD SUITE 307
VIRGINIA BEACH VA
23455-5500
US

IV. Provider business mailing address

1020 INDEPENDENCE BLVD SUITE 307
VIRGINIA BEACH VA
23455-5500
US

V. Phone/Fax

Practice location:
  • Phone: 757-460-3688
  • Fax: 757-460-5516
Mailing address:
  • Phone: 757-460-3688
  • Fax: 757-460-5516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000523
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number0618000523
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: