Provider Demographics
NPI:1144319195
Name:VIRGINIA EYE CLINIC, PLLC
Entity type:Organization
Organization Name:VIRGINIA EYE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:434-239-5323
Mailing Address - Street 1:2413 WARDS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2103
Mailing Address - Country:US
Mailing Address - Phone:434-239-5323
Mailing Address - Fax:434-239-1388
Practice Address - Street 1:2413 WARDS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2103
Practice Address - Country:US
Practice Address - Phone:434-239-5323
Practice Address - Fax:434-239-1388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA06180000530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9230122Medicaid
VA9234501Medicaid
VA6726030001Medicare NSC
VA410000892Medicare ID - Type Unspecified
VA9230122Medicaid
VA9234501Medicaid