Healthcare Provider Details

I. General information

NPI: 1235430992
Provider Name (Legal Business Name): KEITH JAMES OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 07/21/2022
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6828 SPRINGFIELD MALL
SPRINGFIELD VA
22150-1720
US

IV. Provider business mailing address

4231 COLUMBIA PIKE STE 102
ARLINGTON VA
22204-1876
US

V. Phone/Fax

Practice location:
  • Phone: 703-971-2021
  • Fax:
Mailing address:
  • Phone: 571-441-0041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002556
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA-2497
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: