Healthcare Provider Details

I. General information

NPI: 1285288506
Provider Name (Legal Business Name): FABRICE DJOKO DZUGUIA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17301 VALLEY MALL RD
HAGERSTOWN MD
21740-6966
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 301-582-1771
  • Fax: 301-582-4681
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003046
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2073
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2685
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG004107
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: