Healthcare Provider Details

I. General information

NPI: 1225100399
Provider Name (Legal Business Name): ROBERT E TITCOMB OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 INDEPENDENCE BLVD, SUITE 307 HAYGOOD MEDICAL CENTER
VIRGINIA BEACH VA
23455-5543
US

IV. Provider business mailing address

1020 INDEPENDENCE BLVD, SUITE 307 HAYGOOD MEDICAL CENTER
VIRGINIA BEACH VA
23455-5543
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 TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number0618000523
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number06180000523
License Number StateVA

VIII. Authorized Official

Name: DR. ROBERT EDWARD TITCOMB
Title or Position: OPTOMETRIST
Credential: OD
Phone: 757-460-3688