Healthcare Provider Details

I. General information

NPI: 1649685629
Provider Name (Legal Business Name): WARREN GWYNN O.D, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 W STUART DR
HILLSVILLE VA
24343-1577
US

IV. Provider business mailing address

843 W STUART DR
HILLSVILLE VA
24343-1577
US

V. Phone/Fax

Practice location:
  • Phone: 276-728-9323
  • Fax: 276-728-0400
Mailing address:
  • Phone: 276-728-9323
  • Fax: 276-728-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002348
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: