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General NPI Number Information
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NPI Number | 1396757480
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Entity Type | Individual
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Provider Name | RICHARD A VAN DE VELDE OD
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Gender | Male
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Dates
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Enumeration Date | 08/13/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 3215 SHRINE RD SUITE 6
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City | BRUNSWICK
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State | GA
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Zip | 31520
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Country | US
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Telephone | 912-267-0565
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Fax | 912-265-0545
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Provider Business Mailing Address
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Address Line | 3215 SHRINE RD SUITE 6
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City | BRUNSWICK
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State | GA
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Zip | 31520
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Country | US
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Telephone | 912-267-0565
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Fax | 912-265-0545
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | OPT001640
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License Number State | GA
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