Provider Demographics
NPI:1003802422
Name:PEMBERTON, MARY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LEE
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 JEFFERSON HWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-8503
Mailing Address - Country:US
Mailing Address - Phone:540-946-8727
Mailing Address - Fax:540-949-5526
Practice Address - Street 1:2522 JEFFERSON HWY
Practice Address - Street 2:SUITE 106
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-8503
Practice Address - Country:US
Practice Address - Phone:540-946-8727
Practice Address - Fax:540-949-5526
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA061800738152W00000X
VA0618000738152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA466350OtherANTHEM BC/BS
VA5612691OtherCIGNA
VA159075OtherSOUTHERN HEALTH
VA466350OtherANTHEM BC/BS
VA5612691OtherCIGNA