Individual
GORDON W JENNINGS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD PC
Contact information
Practice address
310 E MAIN ST, WYTHEVILLE, VA 24382-2326
(276) 228-2771
(276) 228-9097
Mailing address
310 E MAIN ST, WYTHEVILLE, VA 24382-2326
(276) 228-2771
(276) 228-9097
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
0618000067
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009234268
—
VA
01
—
079556
ANTHEM BCBS
VA
01
—
1669435533
NPI
VA
01
—
541900685
TAX ID
VA
01
—
VA05215911
UMWA
VA
Enumeration date
04/10/2006
Last updated
11/30/2009
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