Provider Demographics
NPI:1407913395
Name:VIRGINIA OCULOFACIAL SURGEONS
Entity Type:Organization
Organization Name:VIRGINIA OCULOFACIAL SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DIMITRIOS
Authorized Official - Middle Name:N
Authorized Official - Last Name:SISMANIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-934-9344
Mailing Address - Street 1:1630 WILKES RIDGE PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7460
Mailing Address - Country:US
Mailing Address - Phone:804-934-9344
Mailing Address - Fax:
Practice Address - Street 1:1630 WILKES RIDGE PKWY STE 102
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-7460
Practice Address - Country:US
Practice Address - Phone:804-934-9344
Practice Address - Fax:804-934-9034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046909174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA143900OtherANTHEM BLUECROSSBLUESHIEL
VI20353OtherOPTIMA HEALTH SENTARA
VA006360092OtherVA PREMIER
VA006360092Medicaid
VA180015571OtherRAILROAD MEDICARE
VA=========OtherSOUTHERN HEALTH