Basic Information
| Provider Information | |||||||||
| NPI: | 1710945035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PILSKALNS | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 E FERRELL ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH HILL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239702101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344473220 | ||||||||
| FaxNumber: | 4344472309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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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 | 5408T2319 | OH | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 0618001558 | VA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 010257042 | 05 | VA | MEDICAID | 194021 | 01 | VA | ANTHEM BCBS EMP PROV # | OTHER | 194019 | 01 | VA | ANTHEM BCBS SOH PROV # | OTHER | P00325745 | 01 | VA | RR MEDICARE INDIVIDUAL # | OTHER | 010285691 | 05 | VA | MEDICAID |