Provider Demographics
NPI:1578638748
Name:TIDEWATER EYE CENTER SPC
Entity type:Organization
Organization Name:TIDEWATER EYE CENTER SPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEVANTIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-483-0400
Mailing Address - Street 1:3235 ACADEMY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3200
Mailing Address - Country:US
Mailing Address - Phone:757-483-0400
Mailing Address - Fax:757-673-6832
Practice Address - Street 1:3235 ACADEMY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3200
Practice Address - Country:US
Practice Address - Phone:757-483-0400
Practice Address - Fax:757-673-6832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05674Medicare PIN
VACN4829Medicare PIN
VACN4826Medicare PIN
VACH5117Medicare PIN
VACN4829Medicare PIN