Provider Demographics
NPI:1578511515
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 1:215 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:KING
Mailing Address - State:NC
Mailing Address - Zip Code:27021-8703
Mailing Address - Country:US
Mailing Address - Phone:336-985-2020
Mailing Address - Fax:336-985-2133
Practice Address - Street 1:215 MOORE RD
Practice Address - Street 2:
Practice Address - City:KING
Practice Address - State:NC
Practice Address - Zip Code:27021-8703
Practice Address - Country:US
Practice Address - Phone:336-985-2020
Practice Address - Fax:336-985-2133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017J1OtherBCBS GRP #
NC5900613Medicaid
NC017J1OtherBCBS GRP #
NC246648TMedicare PIN