Provider Demographics
NPI:1861408858
Name:PALISANO, PAUL J (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:J
Last Name:PALISANO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1290
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-1290
Mailing Address - Country:US
Mailing Address - Phone:434-385-5600
Mailing Address - Fax:434-455-7172
Practice Address - Street 1:2010 BREMO RD STE 128
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2444
Practice Address - Country:US
Practice Address - Phone:804-285-0680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154617OtherUHC
1920517OtherCIGNA
435538OtherSOUTHERN HEALTH
1337863OtherAETNA
239501OtherANTHEM
VA010306264Medicaid
1337863OtherAETNA
1920517OtherCIGNA
011102E10Medicare ID - Type Unspecified