Provider Demographics
NPI:1639405327
Name:CLEARLY OPTOMETRY, PC
Entity Type:Organization
Organization Name:CLEARLY OPTOMETRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:804-353-3555
Mailing Address - Street 1:2038 MONUMENT AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-2708
Mailing Address - Country:US
Mailing Address - Phone:804-353-3555
Mailing Address - Fax:804-353-9630
Practice Address - Street 1:2038 MONUMENT AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-2708
Practice Address - Country:US
Practice Address - Phone:804-353-3555
Practice Address - Fax:804-353-9630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA038113OtherANTHEM
586486OtherUS HEALTHCARE
22-000047OtherUNITED HEALTHCARE
VA89-2028-1Medicaid
VA012848001OtherDMEPOS
VAU21508Medicare UPIN
VA012848001OtherDMEPOS