Provider Demographics
NPI:1295882835
Name:COLONIAL OPTHALMOLOGY
Entity type:Organization
Organization Name:COLONIAL OPTHALMOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-229-4000
Mailing Address - Street 1:5215 MONTICELLO AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-8213
Mailing Address - Country:US
Mailing Address - Phone:757-229-4000
Mailing Address - Fax:
Practice Address - Street 1:5215 MONTICELLO AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-8213
Practice Address - Country:US
Practice Address - Phone:757-229-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0821810001Medicare NSC