Healthcare Provider Details

I. General information

NPI: 1487236626
Provider Name (Legal Business Name): SPECTRUM RETINA & OCULAR ONCOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 BEVERLY RD STE 110
MC LEAN VA
22101-3700
US

IV. Provider business mailing address

1420 BEVERLY RD STE 110
MC LEAN VA
22101-3700
US

V. Phone/Fax

Practice location:
  • Phone: 703-643-9328
  • Fax: 571-378-2237
Mailing address:
  • Phone: 703-643-9328
  • Fax: 571-378-2237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM F DEEGAN III
Title or Position: PRACTICE OWNER
Credential: MD
Phone: 703-643-9328