Healthcare Provider Details

I. General information

NPI: 1255299301
Provider Name (Legal Business Name): PATRICIA CLUBB OD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2026
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10215 CARNOCH WAY STE 113
BRISTOW VA
20136-2725
US

IV. Provider business mailing address

14662 BATTERY RIDGE LN
CENTREVILLE VA
20120-2896
US

V. Phone/Fax

Practice location:
  • Phone: 571-732-8009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICIA CLUBB
Title or Position: OWNER
Credential: OD, MS
Phone: 571-723-8009