Provider Demographics
NPI:1437148509
Name:HILVERSUM, CHEQUITA (OD)
Entity Type:Individual
Prefix:MS
First Name:CHEQUITA
Middle Name:
Last Name:HILVERSUM
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:212 STATE ROAD 312
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4241
Practice Address - Country:US
Practice Address - Phone:904-824-2021
Practice Address - Fax:904-824-2039
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC-2951152W00000X
FLOPC2951152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59359043OtherTRICARE
FL59359043OtherTRICARE
FLE1338Medicare ID - Type Unspecified