Provider Demographics
NPI:1417130964
Name:ALLEN, NEYSA ANGLE (OD)
Entity Type:Individual
Prefix:DR
First Name:NEYSA
Middle Name:ANGLE
Last Name:ALLEN
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 1:4135 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5703
Mailing Address - Country:US
Mailing Address - Phone:540-776-2930
Mailing Address - Fax:540-776-2932
Practice Address - Street 1:4135 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-5703
Practice Address - Country:US
Practice Address - Phone:540-776-2930
Practice Address - Fax:540-776-2932
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000252152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009234560Medicaid
VA009234560Medicaid
VAT83548Medicare PIN
VA410001064Medicare PIN