Provider Demographics
NPI:1235272048
Name:WILLIAMSBURG RETINA CENTER, PLLC
Entity Type:Organization
Organization Name:WILLIAMSBURG RETINA CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:NORDLUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-220-3375
Mailing Address - Street 1:113 BULIFANTS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5709
Mailing Address - Country:US
Mailing Address - Phone:757-220-3375
Mailing Address - Fax:757-220-3380
Practice Address - Street 1:113 BULIFANTS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5709
Practice Address - Country:US
Practice Address - Phone:757-220-3375
Practice Address - Fax:757-220-3380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048352207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09620Medicare ID - Type UnspecifiedGROUP NUMBER