Healthcare Provider Details

I. General information

NPI: 1790134807
Provider Name (Legal Business Name): WILLIAM REID MOUGHON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19415 DEERFIELD AVE SUITE 106
LANSDOWNE VA
20176-8452
US

IV. Provider business mailing address

19415 DEERFIELD AVE SUITE 106
LANSDOWNE VA
20176-8452
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-9633
  • Fax: 703-723-9772
Mailing address:
  • Phone: 703-723-9633
  • Fax: 703-723-9772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002502
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: