Healthcare Provider Details

I. General information

NPI: 1285293100
Provider Name (Legal Business Name): HARES BANUWAL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6178 OXON HILL RD STE 100
OXON HILL MD
20745-3161
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 301-839-5555
  • Fax: 301-839-1867
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 Number0618003161
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0618003161
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2676
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: