Provider Demographics
NPI:1164514311
Name:RAINER, ROBERT GREGG (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GREGG
Last Name:RAINER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5617 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2614
Mailing Address - Country:US
Mailing Address - Phone:804-282-7228
Mailing Address - Fax:804-285-3781
Practice Address - Street 1:5617 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2614
Practice Address - Country:US
Practice Address - Phone:804-282-7228
Practice Address - Fax:804-285-3781
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000110152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9237411Medicaid
VA9237411Medicaid
VAT98020Medicare UPIN
VA0319490001Medicare NSC