Provider Demographics
NPI:1184660227
Name:CLARK-GELBURD, KATHLEEN J (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:J
Last Name:CLARK-GELBURD
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:400 S MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-3648
Practice Address - Country:US
Practice Address - Phone:540-949-7126
Practice Address - Fax:540-943-6170
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000978152WC0802X, 152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA033512OtherANTHEM-VIRGINIA
VA92-3089-1Medicaid
VA92-3089-1Medicaid