Basic Information
| Provider Information | |||||||||
| NPI: | 1285656082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALEY | ||||||||
| FirstName: | BILLY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALEY | ||||||||
| OtherFirstName: | DOUGLAS | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1290 | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245511290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343855600 | ||||||||
| FaxNumber: | 4344557172 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 GRAVES MILL RD | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245513967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343855600 | ||||||||
| FaxNumber: | 4344557172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618000386 | VA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 009232346 | 05 | VA | MEDICAID |