Provider Demographics
NPI:1952787244
Name:NORTHERN VIRGINIA EYE INSTITUTE
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA EYE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SISKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-483-7463
Mailing Address - Street 1:311 PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:727-483-7463
Mailing Address - Fax:727-755-0679
Practice Address - Street 1:212 LINDEN DR
Practice Address - Street 2:SUITE 154
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2894
Practice Address - Country:US
Practice Address - Phone:540-313-4435
Practice Address - Fax:540-313-4438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237120207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC09274Medicare PIN