Provider Demographics
NPI:1134354897
Name:W. BERRY MAULTSBY, JR., O.D., P.C.
Entity type:Organization
Organization Name:W. BERRY MAULTSBY, JR., O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:BERRY
Authorized Official - Last Name:MAULTSBY
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:434-791-3937
Mailing Address - Street 1:413 MT. CROSS ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540
Mailing Address - Country:US
Mailing Address - Phone:434-791-3937
Mailing Address - Fax:434-791-2468
Practice Address - Street 1:413 MT. CROSS ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540
Practice Address - Country:US
Practice Address - Phone:434-791-3937
Practice Address - Fax:434-791-2468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000688152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
465270OtherANTHEM
VA010337861Medicaid
VA010337861Medicaid