Healthcare Provider Details

I. General information

NPI: 1013358514
Provider Name (Legal Business Name): EYEDATA - EYE DOCTORS AND TECHNOLOGY ADVANTAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S WASHINGTON ST
FALLS CHURCH VA
22046-4412
US

IV. Provider business mailing address

410 S WASHINGTON ST
FALLS CHURCH VA
22046-4412
US

V. Phone/Fax

Practice location:
  • Phone: 703-532-0728
  • Fax:
Mailing address:
  • Phone: 703-532-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberD0069016
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMD037754
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0101249765
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GUSTAVO ADOLFO CORRALES REGALADO
Title or Position: DIRECTOR
Credential: M.D.
Phone: 301-335-5860