=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154535623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYELID & OCULOPLASTIC CONSULTANTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1821 OLD DONATION PKWY SUITE 6
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-496-4864
-----------------------------------------------------
Fax | 757-496-4942
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1821 OLD DONATION PKWY SUITE 6
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-496-4864
-----------------------------------------------------
Fax | 757-496-4942
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MATTHEW JAMES MITSCH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 757-496-4864
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0101052465
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------