Provider Demographics
NPI:1023364601
Name:CHILDERS-PITTMAN, ALYSSA MACKENZIE (OD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MACKENZIE
Last Name:CHILDERS-PITTMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:MACKENZIE
Other - Last Name:CHILDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:530 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-3171
Mailing Address - Country:US
Mailing Address - Phone:540-338-1833
Mailing Address - Fax:
Practice Address - Street 1:530 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-3171
Practice Address - Country:US
Practice Address - Phone:540-338-1833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1095-IOD152W00000X
PAOEG002638152W00000X
OH6112152W00000X
VA0618002316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVE942AOtherMEDICARE PTAN