Provider Demographics
NPI:1437712767
Name:DORGELOH, KYRA
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:DORGELOH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 TUCKAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2139
Mailing Address - Country:US
Mailing Address - Phone:919-943-1060
Mailing Address - Fax:
Practice Address - Street 1:601 N COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-4062
Practice Address - Country:US
Practice Address - Phone:804-858-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009007152W00000X
VA0618002829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist