Provider Demographics
NPI:1154535623
Name:EYELID & OCULOPLASTIC CONSULTANTS, PC
Entity type:Organization
Organization Name:EYELID & OCULOPLASTIC CONSULTANTS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MITSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-496-4864
Mailing Address - Street 1:1821 OLD DONATION PKWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3033
Mailing Address - Country:US
Mailing Address - Phone:757-496-4864
Mailing Address - Fax:757-496-4942
Practice Address - Street 1:1821 OLD DONATION PKWY
Practice Address - Street 2:SUITE 6
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3033
Practice Address - Country:US
Practice Address - Phone:757-496-4864
Practice Address - Fax:757-496-4942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052465174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6900925Medicaid
VAG12085Medicare UPIN