Basic Information
| Provider Information | |||||||||
| NPI: | 1437193125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS VISION CENTER OD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 WALDEN RIDGE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288038586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286815959 | ||||||||
| FaxNumber: | 8286815960 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 WALDEN RIDGE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288038586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286815959 | ||||||||
| FaxNumber: | 8286815960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | BURGESS | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2524420802 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 5903903 | 05 | NC | MEDICAID | 018GY | 01 | NC | BCBS GROUP NUMBER | OTHER |