=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740479088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS. WEISS OPTOMETRISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2007
-----------------------------------------------------
Last Update Date | 10/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4321 JAMES MADISON HWY #2
-----------------------------------------------------
City | FORK UNION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23055-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-842-3364
-----------------------------------------------------
Fax | 434-842-3363
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 517
-----------------------------------------------------
City | FORK UNION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23055-0517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-842-3364
-----------------------------------------------------
Fax | 434-842-3363
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DOUGLAS FLOYD WEISS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 434-842-3364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618000628
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------