Provider Demographics
NPI:1629121983
Name:ELDER, JERRY CURTIS (OPTICIAN PRESIDENT O)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:CURTIS
Last Name:ELDER
Suffix:
Gender:M
Credentials:OPTICIAN PRESIDENT O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 LANGHORNE ROAD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1424
Mailing Address - Country:US
Mailing Address - Phone:434-845-6120
Mailing Address - Fax:434-845-6120
Practice Address - Street 1:2124 LANGHORNE ROAD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1424
Practice Address - Country:US
Practice Address - Phone:434-845-6120
Practice Address - Fax:434-845-6120
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA433156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0302980001Medicare ID - Type Unspecified