Healthcare Provider Details

I. General information

NPI: 1538155577
Provider Name (Legal Business Name): STEVEN MICHAEL LADERBERG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
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:
Title or Position:
Credential:
Phone: