Basic Information
| Provider Information | |||||||||
| NPI: | 1730158080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOTY | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1290 | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245511290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343855600 | ||||||||
| FaxNumber: | 4344557172 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MEMORIAL DR STE A | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245411680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4347993232 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 07/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618002914 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 174400000X | 4188 T45 | OH | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0802402 | 05 | OH | MEDICAID |