Healthcare Provider Details

I. General information

NPI: 1386760247
Provider Name (Legal Business Name): POTOMAC EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411A BACKLICK RD
SPRINGFIELD VA
22151-3915
US

IV. Provider business mailing address

5411A BACKLICK RD
SPRINGFIELD VA
22151-3915
US

V. Phone/Fax

Practice location:
  • Phone: 703-256-2474
  • Fax: 703-941-7938
Mailing address:
  • Phone: 703-256-2474
  • Fax: 703-941-7938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101023876
License Number StateVA

VIII. Authorized Official

Name: DOUGLAS JAMES FRASER JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 703-256-2474