Provider Demographics
NPI:1417063744
Name:KINGSLEY, DANIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:KINGSLEY
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 1:1059 VISTA PARK DR STE C
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4952
Mailing Address - Country:US
Mailing Address - Phone:434-385-5600
Mailing Address - Fax:
Practice Address - Street 1:100 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1537
Practice Address - Country:US
Practice Address - Phone:434-392-8113
Practice Address - Fax:434-392-5934
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA242205OtherANTHEM
VA009235060Medicaid
VA242205OtherANTHEM
VA410001065Medicare ID - Type Unspecified