Provider Demographics
NPI:1679560254
Name:BREWER-LORD, AMANDA (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:BREWER-LORD
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 1:530 W RIDGE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1188
Mailing Address - Country:US
Mailing Address - Phone:276-223-0033
Mailing Address - Fax:276-223-0327
Practice Address - Street 1:530 W RIDGE RD
Practice Address - Street 2:SUITE B
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1042
Practice Address - Country:US
Practice Address - Phone:276-223-0033
Practice Address - Fax:276-223-0327
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000743152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010298458Medicaid
VAU70612Medicare UPIN
VA010298458Medicaid