Healthcare Provider Details

I. General information

NPI: 1649259805
Provider Name (Legal Business Name): DAVID G CORCORAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2006
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MILLS AVE
GREENVILLE SC
29605-4020
US

IV. Provider business mailing address

1950 OLD GALLOWS RD SUITE 520
VIENNA VA
22182-3990
US

V. Phone/Fax

Practice location:
  • Phone: 864-232-2779
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax: 703-991-0514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number948
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number948
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: