Provider Demographics
NPI:1396949046
Name:PETERSBURG FAMILY EYE CARE
Entity type:Organization
Organization Name:PETERSBURG FAMILY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TESTAMARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:804-898-3373
Mailing Address - Street 1:44 MEDICAL PARK BLVD
Mailing Address - Street 2:STE H
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9349
Mailing Address - Country:US
Mailing Address - Phone:804-898-3373
Mailing Address - Fax:804-479-3775
Practice Address - Street 1:44 MEDICAL PARK BLVD
Practice Address - Street 2:STE H
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9349
Practice Address - Country:US
Practice Address - Phone:804-898-3373
Practice Address - Fax:804-479-3775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010315891Medicaid
VA010315891Medicaid
VAY27443Medicare UPIN