Provider Demographics
NPI:1437193125
Name:DOCTORS VISION CENTER OD PA
Entity Type:Organization
Organization Name:DOCTORS VISION CENTER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-442-0802
Mailing Address - Street 1:3 WALDEN RIDGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-8586
Mailing Address - Country:US
Mailing Address - Phone:828-681-5959
Mailing Address - Fax:828-681-5960
Practice Address - Street 1:3 WALDEN RIDGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-8586
Practice Address - Country:US
Practice Address - Phone:828-681-5959
Practice Address - Fax:828-681-5960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903903Medicaid
NC018GYOtherBCBS GROUP NUMBER
NC018GYOtherBCBS GROUP NUMBER
NC5903903Medicaid
NC0139010032Medicare NSC