Healthcare Provider Details

I. General information

NPI: 1396778460
Provider Name (Legal Business Name): BRETT EDWARD ZWOLENSKY O.D., F.A.A.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MED CENTER DR EYE CLINIC
CLARKSBURG WV
26301-4155
US

IV. Provider business mailing address

138 SHERWOOD RD
BRIDGEPORT WV
26330-1040
US

V. Phone/Fax

Practice location:
  • Phone: 304-623-3461
  • Fax: 304-626-7748
Mailing address:
  • Phone: 304-641-9504
  • Fax: 304-626-7748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0000002290
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: