Healthcare Provider Details

I. General information

NPI: 1811231814
Provider Name (Legal Business Name): MARYLAND VISION INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 CHAMPION DR SUITE 100
HAGERSTOWN MD
21740-6558
US

IV. Provider business mailing address

220 CHAMPION DR SUITE 100
HAGERSTOWN MD
21740-6558
US

V. Phone/Fax

Practice location:
  • Phone: 301-791-0888
  • Fax: 301-791-3611
Mailing address:
  • Phone: 301-791-0888
  • Fax: 301-791-3611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. AUGUSTUS G STERN
Title or Position: OWNER
Credential: M.D.
Phone: 504-723-0673