Provider Demographics
NPI:1598820680
Name:WYTHE EYE ASSOCIATES AMANDA BREWER-SMITH OD INC
Entity Type:Organization
Organization Name:WYTHE EYE ASSOCIATES AMANDA BREWER-SMITH OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER LORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:276-223-0033
Mailing Address - Street 1:PO BOX 914
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-0914
Mailing Address - Country:US
Mailing Address - Phone:276-223-0033
Mailing Address - Fax:276-223-0327
Practice Address - Street 1:530 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1188
Practice Address - Country:US
Practice Address - Phone:276-223-0033
Practice Address - Fax:276-223-0327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000743152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010298458Medicaid
VA1218840001Medicare NSC
VA010298458Medicaid