Basic Information
| Provider Information | |||||||||
| NPI: | 1972561660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS VISION CENTER OD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7396 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529851371 | ||||||||
| FaxNumber: | 2529852303 | ||||||||
| Practice Location | |||||||||
| Address1: | 413 MILL ST | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278044837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529851371 | ||||||||
| FaxNumber: | 2529852303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | BURGESS | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2529851371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 019E5 | 01 | NC | BCBS OF NC GROUP NUMBER | OTHER | 5906240 | 05 | NC | MEDICAID | CJ5982 | 01 | NC | RR MEDICARE GROUP | OTHER |