Provider Demographics
NPI:1902808710
Name:TESTAMARK, PATRICIA LOUISE (OD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:LOUISE
Last Name:TESTAMARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:PATRICIA
Other - Middle Name:LOUISE
Other - Last Name:TESTAMARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:44 MEDICAL PARK BLVD
Mailing Address - Street 2:STE H
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9349
Mailing Address - Country:US
Mailing Address - Phone:804-898-3373
Mailing Address - Fax:804-479-3775
Practice Address - Street 1:44 MEDICAL PARK BLVD
Practice Address - Street 2:STE H
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9349
Practice Address - Country:US
Practice Address - Phone:804-898-3373
Practice Address - Fax:804-479-3775
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010315891Medicaid
VA010315891Medicaid
VA010315891Medicaid