Provider Demographics
NPI:1215101126
Name:DRS. GARDNER & VELOSO
Entity type:Organization
Organization Name:DRS. GARDNER & VELOSO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:VELOSO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:540-342-6294
Mailing Address - Street 1:307 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1901
Mailing Address - Country:US
Mailing Address - Phone:540-342-6294
Mailing Address - Fax:540-342-8201
Practice Address - Street 1:307 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24011-1901
Practice Address - Country:US
Practice Address - Phone:540-342-6294
Practice Address - Fax:540-342-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001002332900000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9232249Medicaid
VA410001159Medicare PIN
VA9232249Medicaid