Healthcare Provider Details

I. General information

NPI: 1053761122
Provider Name (Legal Business Name): STEPHAN EUGENE HANOWSKY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S HAYES ST
ARLINGTON VA
22202-4907
US

IV. Provider business mailing address

1100 S HAYES ST
ARLINGTON VA
22202-4907
US

V. Phone/Fax

Practice location:
  • Phone: 703-415-5544
  • Fax:
Mailing address:
  • Phone: 703-415-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002508
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: