Provider Demographics
NPI:1326006503
Name:DOCTORS VISION CENTER OD PA
Entity Type:Organization
Organization Name:DOCTORS VISION CENTER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:2529-851-3714
Mailing Address - Street 1:601 W STATE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-6300
Mailing Address - Country:US
Mailing Address - Phone:252-669-2747
Mailing Address - Fax:252-669-2749
Practice Address - Street 1:601 W STATE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-6300
Practice Address - Country:US
Practice Address - Phone:252-669-2747
Practice Address - Fax:252-669-2749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016UCOtherBCBS GRP #