Provider Demographics
NPI:1174891295
Name:URBAN, BERNHARD J (OPT)
Entity type:Individual
Prefix:MR
First Name:BERNHARD
Middle Name:J
Last Name:URBAN
Suffix:
Gender:M
Credentials:OPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12704 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-5369
Mailing Address - Country:US
Mailing Address - Phone:804-237-9195
Mailing Address - Fax:
Practice Address - Street 1:12704 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-5369
Practice Address - Country:US
Practice Address - Phone:804-237-9195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-03
Last Update Date:2011-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101002897156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician