Provider Demographics
NPI:1972561660
Name:DOCTORS VISION CENTER OD PA
Entity type:Organization
Organization Name:DOCTORS VISION CENTER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-985-1371
Mailing Address - Street 1:PO BOX 7396
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0396
Mailing Address - Country:US
Mailing Address - Phone:252-985-1371
Mailing Address - Fax:252-985-2303
Practice Address - Street 1:413 MILL ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-4837
Practice Address - Country:US
Practice Address - Phone:252-985-1371
Practice Address - Fax:252-985-2303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC019E5OtherBCBS OF NC GROUP NUMBER
NC5906240Medicaid
NCCJ5982OtherRR MEDICARE GROUP
NC019E5OtherBCBS OF NC GROUP NUMBER