Provider Demographics
NPI:1316029739
Name:TESER, NICOLE G (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:G
Last Name:TESER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:21475 RIDGETOP CIRCLE SUITE 300
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-8580
Practice Address - Country:US
Practice Address - Phone:703-430-4400
Practice Address - Fax:703-430-4130
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA175691OtherANTHEM BCBS/HEALTHKEEPERS
VA175687OtherANTHEM BCBS/HEALTHKEEPERS
VA175689OtherANTHEM BCBS/HEALTHKEEPERS
VA010118727Medicaid
VA010118654Medicaid
VA010118760Medicaid
VA010118794Medicaid
VA1316029739Medicaid
VA175682OtherANTHEM BCBS/HEALTHKEEPERS
VA010118654Medicaid
VA010118760Medicaid
VA175689OtherANTHEM BCBS/HEALTHKEEPERS