Basic Information
| Provider Information | |||||||||
| NPI: | 1215101126 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRS. GARDNER & VELOSO | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 307 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403426294 | ||||||||
| FaxNumber: | 5403428201 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403426294 | ||||||||
| FaxNumber: | 5403428201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 08/15/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VELOSO | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5403426294 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 0618001002 | VA | N | Suppliers | Non-Pharmacy Dispensing Site | 332H00000X | 0618001002 | VA | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 9232249 | 05 | VA | MEDICAID |