Provider Demographics
NPI:1548314388
Name:BAZEMORE, TENESHA A (OD)
Entity type:Individual
Prefix:DR
First Name:TENESHA
Middle Name:A
Last Name:BAZEMORE
Suffix:
Gender:F
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 1612
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-1612
Mailing Address - Country:US
Mailing Address - Phone:757-470-0789
Mailing Address - Fax:
Practice Address - Street 1:6111 JEFFERSON AVE STE 1
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23605-1511
Practice Address - Country:US
Practice Address - Phone:757-867-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1404-548T152W00000X
PAOE007871T152W00000X
VA0618000570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA92-3420-9Medicaid
VA41-000-1083Medicare ID - Type Unspecified
VA92-3420-9Medicaid