MEDICARE: DR. KENNETH A LEBOW O.D., F.A.A.O.

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	152WC0802X	Corneal and Contact Management Optometrist	0618001847	VA
2	152WC0802X	Corneal and Contact Management Optometrist	0618000344	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	006473	OTHER	VA	BLUE CROSS BLUE SHIELD
2	VA0000456	OTHER	VA	TRICARE/CHAMPUS

General Provider Information

NPI Number	:	1902892599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH A LEBOW O.D., F.A.A.O.

Provider Business Mailing Address
First Line	:	345 EDWIN DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4522
Country	:	US
Telephone Number	:	757-497-5555
Fax Number	:	757-499-2636

Provider Business Practice Location Address
First Line	:	345 EDWIN DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4522
Country	:	US
Telephone Number	:	757-497-5555
Fax Number	:	757-499-2636

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	09/07/2023

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