Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 0618000978 | VA |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 0618000978 | VA |
N | 152WP0200X | Pediatric Optomitrist | 0618000978 | VA |
N | 152WV0400X | Optomitrist - Vision Therapist | 0618000978 | VA |
NPI | 1184660227 |
---|---|
Provider Name | Dr. Kathleen J Clark-Gelburd |
First Address | Vienna, VA 22182-3970 |
Second Address | Waynesboro, VA 22980-3648 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2006 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
033512 | ANTHEM-VIRGINIA (01) | VA |
V18908 | (02) | VA |