Provider Demographics
NPI:1780961086
Name:VIRGINIA PEDIATRIC OPHTHALMOLOGY SPECIALISTS, LLC
Entity type:Organization
Organization Name:VIRGINIA PEDIATRIC OPHTHALMOLOGY SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHAM
Authorized Official - Suffix:V
Authorized Official - Credentials:MD
Authorized Official - Phone:804-272-8040
Mailing Address - Street 1:8720 STONY POINT PKWY
Mailing Address - Street 2:SUITE 135
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-1962
Mailing Address - Country:US
Mailing Address - Phone:804-272-8040
Mailing Address - Fax:804-272-7344
Practice Address - Street 1:8720 STONY POINT PKWY
Practice Address - Street 2:SUITE 135
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-1962
Practice Address - Country:US
Practice Address - Phone:804-272-8040
Practice Address - Fax:804-272-7344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047478174400000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010271259OtherMEDICAL LICENSE