Basic Information
Provider Information | |||||||||
NPI: | 1265437164 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEROME | ||||||||
FirstName: | VALARIE | ||||||||
MiddleName: | SIMPSON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SIMPSON | ||||||||
OtherFirstName: | VALARIE | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | O.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2215 MEMORIAL DR | ||||||||
Address2: | #25 | ||||||||
City: | WAYCROSS | ||||||||
State: | GA | ||||||||
PostalCode: | 315010983 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9122852021 | ||||||||
FaxNumber: | 9122852558 | ||||||||
Practice Location | |||||||||
Address1: | 1111 E MAIN ST | ||||||||
Address2: | STE 120 | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232193500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8046480900 | ||||||||
FaxNumber: | 8046484367 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2005 | ||||||||
LastUpdateDate: | 02/07/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT002565 | GA | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 010104017 | 05 | VA |   | MEDICAID |