Healthcare Provider Details

I. General information

NPI: 1376288597
Provider Name (Legal Business Name): JAMES W MATTERN OD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 HAMAKER CT STE 101
FAIRFAX VA
22031-2229
US

IV. Provider business mailing address

3025 HAMAKER CT STE 101
FAIRFAX VA
22031-2229
US

V. Phone/Fax

Practice location:
  • Phone: 703-876-9630
  • Fax: 703-876-0163
Mailing address:
  • Phone: 703-876-9630
  • Fax: 703-876-0163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES W MATTERN
Title or Position: OWNER/PRESIDENT
Credential: OD
Phone: 703-876-9630