Provider Demographics
NPI:1205997764
Name:DOUGLAS & VICTORIA M WEISS
Entity type:Organization
Organization Name:DOUGLAS & VICTORIA M WEISS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:50 PARTNER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:MOLNAR
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:434-591-0262
Mailing Address - Street 1:5B CENTRE CT
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-2329
Mailing Address - Country:US
Mailing Address - Phone:434-591-0262
Mailing Address - Fax:434-591-0111
Practice Address - Street 1:5B CENTRE CT
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-2329
Practice Address - Country:US
Practice Address - Phone:434-591-0262
Practice Address - Fax:434-591-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000628152W00000X, 152WL0500X, 152WV0400X
VA0618000665152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA146815OtherSOUTHERN HEALTH
VA9234306Medicaid
VA219852OtherANTHEM
VA151998OtherSOUTHERN HEALTH
VA224432OtherANTHEM
VA9234292Medicaid
VA146815OtherSOUTHERN HEALTH
VA151998OtherSOUTHERN HEALTH
T93324Medicare UPIN
VA410001096Medicare PIN