MEDICARE: GLAUCOMA LASER CENTER PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician
2	207WX0009X	Glaucoma Specialist (Ophthalmology) Physician	0101052595	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	242315	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1891791521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLAUCOMA LASER CENTER PC

Provider Business Mailing Address
First Line	:	160 KINGSLEY LN
Second Line	:	STE 300
City	:	NORFOLK
State	:	VA
Zip	:	23505-4600
Country	:	US
Telephone Number	:	757-440-1144
Fax Number	:	757-440-1117

Provider Business Practice Location Address
First Line	:	160 KINGSLEY LN
Second Line	:	STE 300
City	:	NORFOLK
State	:	VA
Zip	:	23505-4600
Country	:	US
Telephone Number	:	757-440-1144
Fax Number	:	757-440-1117

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAWNIELLE J KERNER
Credential	:	MD
Telephone Number	:	757-440-1144

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/21/2022

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