Provider Demographics
NPI:1639181472
Name:MURTAZA, KULSOOM T (OD)
Entity Type:Individual
Prefix:
First Name:KULSOOM
Middle Name:T
Last Name:MURTAZA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:400 WESTHAMPTON STA
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3330
Mailing Address - Country:US
Mailing Address - Phone:804-287-4200
Mailing Address - Fax:804-287-4210
Practice Address - Street 1:2015 WATERSIDE RD
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1265
Practice Address - Country:US
Practice Address - Phone:804-733-7300
Practice Address - Fax:804-733-7390
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001931152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKM003908OtherSTATE LICENSE NUMBER
MI900C363570OtherBLUE CROSS BLUE SHIELD
MI200000002790OtherPHPMM
VA0618001931OtherSTATE LICENSE
MI900C363570OtherBLUE CROSS BLUE SHIELD
MIV10365Medicare UPIN