Healthcare Provider Details

I. General information

NPI: 1750512257
Provider Name (Legal Business Name): JEFFREY I WYNN OD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17614 MAIN ST
DUMFRIES VA
22026-2359
US

IV. Provider business mailing address

17614 MAIN ST
DUMFRIES VA
22026-2359
US

V. Phone/Fax

Practice location:
  • Phone: 703-221-3575
  • Fax: 703-221-4416
Mailing address:
  • Phone: 703-221-3575
  • Fax: 703-221-4416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000150
License Number StateVA

VIII. Authorized Official

Name: DR. JEFFREY IAN WYNN
Title or Position: PRESIDENT
Credential: OD
Phone: 703-221-3575