Provider Demographics
NPI:1659696391
Name:JAMES RIVER EYE PHYSICIANS
Entity Type:Organization
Organization Name:JAMES RIVER EYE PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE REPRESENTATIVE
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-595-8404
Mailing Address - Street 1:704 THIMBLE SHOALS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4544
Mailing Address - Country:US
Mailing Address - Phone:757-595-8404
Mailing Address - Fax:757-595-8353
Practice Address - Street 1:704 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4544
Practice Address - Country:US
Practice Address - Phone:757-595-8404
Practice Address - Fax:757-595-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000430152W00000X
VA0618001144152W00000X
VA0618001735152W00000X
VA0101041607207W00000X
VA0101056628207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006305547Medicaid
324304OtherANTHEM BCBS
VA1881655058Medicare NSC
VA006305547Medicaid