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General NPI Number Information
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NPI Number | 1134354897
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Entity Type | Organization
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Legal Business Name | W. BERRY MAULTSBY, JR., O.D., P.C.
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Dates
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Enumeration Date | 05/26/2009
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Last Update Date | 06/02/2009
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Provider Practice Location Address
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Address Line | 413 MT. CROSS ROAD SUITE 203
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City | DANVILLE
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State | VA
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Zip | 24540
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Country | US
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Telephone | 434-791-3937
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Fax | 434-791-2468
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Provider Business Mailing Address
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Address Line | 413 MT. CROSS ROAD SUITE 203
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City | DANVILLE
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State | VA
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Zip | 24540
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Country | US
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Telephone | 434-791-3937
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Fax | 434-791-2468
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. WALLACE BERRY MAULTSBY JR.
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Credential | O.D.
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Telephone | 434-791-3937
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618000688
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License Number State | VA
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