Provider Demographics
NPI:1891791521
Name:GLAUCOMA LASER CENTER PC
Entity Type:Organization
Organization Name:GLAUCOMA LASER CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWNIELLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-440-1144
Mailing Address - Street 1:160 KINGSLEY LN
Mailing Address - Street 2:STE 300
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4600
Mailing Address - Country:US
Mailing Address - Phone:757-440-1144
Mailing Address - Fax:757-440-1117
Practice Address - Street 1:160 KINGSLEY LN
Practice Address - Street 2:STE 300
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4600
Practice Address - Country:US
Practice Address - Phone:757-440-1144
Practice Address - Fax:757-440-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207W00000X
VA0101052595207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006304869Medicaid
VA242315OtherANTHEM
VA180000723Medicare ID - Type Unspecified