Provider Demographics
NPI:1346226008
Name:BATAC, THERESA L (OD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:L
Last Name:BATAC
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 1:2233 HAVERSHAM CLOSE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1152
Mailing Address - Country:US
Mailing Address - Phone:757-496-5898
Mailing Address - Fax:
Practice Address - Street 1:7525 TIDEWATER DR STE 41
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-3700
Practice Address - Country:US
Practice Address - Phone:757-588-5423
Practice Address - Fax:757-588-6012
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA601001676152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X
VA0618000007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9232559Medicaid
1801903745OtherGROUP NPI
51-0558604OtherTAXID CORP
1801903745OtherGROUP NPI
51-0558604OtherTAXID CORP
TX410047734Medicare ID - Type UnspecifiedPALMETTO
VA410001132Medicare ID - Type UnspecifiedTRAILBLAZER