Provider Demographics
NPI:1386650042
Name:SEGELEON, BRENT (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:SEGELEON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5273 JOHN TYLER HWY
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-2553
Mailing Address - Country:US
Mailing Address - Phone:757-903-2633
Mailing Address - Fax:757-903-2634
Practice Address - Street 1:5273 JOHN TYLER HWY
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2553
Practice Address - Country:US
Practice Address - Phone:757-903-2633
Practice Address - Fax:757-903-2634
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010307571Medicaid
DCG02638W03Medicare PIN
VA020124L96Medicare PIN
VAP00765011Medicare PIN
VAP00757477Medicare PIN
VA010307571Medicaid
VA010812W00Medicare PIN