Healthcare Provider Details

I. General information

NPI: 1366549289
Provider Name (Legal Business Name): CAREY PAGE WILLEY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 RACE ST
CAMBRIDGE MD
21613-1835
US

IV. Provider business mailing address

101 BAY VIEW AVE
CAMBRIDGE MD
21613-1104
US

V. Phone/Fax

Practice location:
  • Phone: 410-228-0500
  • Fax:
Mailing address:
  • Phone: 410-228-0415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1367-501T
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1807
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: