Provider Demographics
NPI:1801844840
Name:DOCTORS VISION CENTER OD PA
Entity Type:Organization
Organization Name:DOCTORS VISION CENTER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-442-0802
Mailing Address - Street 1:335 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-9200
Mailing Address - Country:US
Mailing Address - Phone:336-591-7428
Mailing Address - Fax:336-591-5136
Practice Address - Street 1:335 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT COVE
Practice Address - State:NC
Practice Address - Zip Code:27052-9200
Practice Address - Country:US
Practice Address - Phone:336-591-7428
Practice Address - Fax:336-591-5136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017J2OtherBCBS GRP #
NC5900612Medicaid
NC246648UMedicare PIN
NC0139010030Medicare NSC