Healthcare Provider Details

I. General information

NPI: 1861435570
Provider Name (Legal Business Name): CHRISTINE BURRIS WISECARVER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8138 WATSON ST
MC LEAN VA
22102-4416
US

IV. Provider business mailing address

8138 WATSON ST
MC LEAN VA
22102-4416
US

V. Phone/Fax

Practice location:
  • Phone: 703-827-5454
  • Fax: 703-827-5539
Mailing address:
  • Phone: 703-827-5454
  • Fax: 703-827-5539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA1779
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP1000091
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001454
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: