1386760247 NPI number — POTOMAC EYE CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386760247 NPI number — POTOMAC EYE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POTOMAC EYE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386760247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5411A BACKLICK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22151-3915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-256-2474
Provider Business Mailing Address Fax Number:
703-941-7938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5411A BACKLICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22151-3915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-256-2474
Provider Business Practice Location Address Fax Number:
703-941-7938
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FRASER
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-256-2474

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  0101023876 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 244846 . This is a "NCPPO PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 78521 . This is a "AETNA PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2146733 . This is a "MDIPA PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2146733 . This is a "ONENETALLIANCE PROV NO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 08 00148 . This is a "UNITED HEALTH CARE PROV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16820001 . This is a "CARE FIRST BCBS PROV NO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 698420 . This is a "FIRST HEALTH PROV NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16820001 . This is a "BCBS NATL CAPITAL PROV NO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2146733 . This is a "MAMSI PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2146733 . This is a "OPTIMUM CHOICE PROV NO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 274557 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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