Healthcare Provider Details

I. General information

NPI: 1902892599
Provider Name (Legal Business Name): KENNETH A LEBOW O.D., F.A.A.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 EDWIN DR
VIRGINIA BEACH VA
23462-4522
US

IV. Provider business mailing address

345 EDWIN DR
VIRGINIA BEACH VA
23462-4522
US

V. Phone/Fax

Practice location:
  • Phone: 757-497-5555
  • Fax: 757-499-2636
Mailing address:
  • Phone: 757-497-5555
  • Fax: 757-499-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618001847
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618000344
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: