=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124474739
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. VERA DHAM & ASSOCIATES OD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2016
-----------------------------------------------------
Last Update Date | 05/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7135 STAPLES MILL RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23228-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-264-7095
-----------------------------------------------------
Fax | 804-264-7097
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7135 STAPLES MILL RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23228-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-264-7095
-----------------------------------------------------
Fax | 804-264-7097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | VIJAYATA DHAM
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 804-252-9827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618002251
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------