Provider Demographics
NPI:1033493275
Name:O VICTOR WEATHERHOLT PC
Entity Type:Organization
Organization Name:O VICTOR WEATHERHOLT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:WEATHERHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:434-385-5318
Mailing Address - Street 1:1912 GRAVES MILL RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4237
Mailing Address - Country:US
Mailing Address - Phone:434-385-7898
Mailing Address - Fax:434-385-1421
Practice Address - Street 1:1912 GRAVES MILL RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4237
Practice Address - Country:US
Practice Address - Phone:434-385-7898
Practice Address - Fax:434-385-1421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000350152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009200703Medicaid