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General NPI Number Information
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NPI Number | 1104973205
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Entity Type | Individual
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Provider Name | JAMES W MATTERN O.D.
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Gender | Male
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 04/03/2012
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Provider Practice Location Address
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Address Line | 3025 HAMAKER CT STE 101
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City | FAIRFAX
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State | VA
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Zip | 22031-2229
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Country | US
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Telephone | 703-876-9630
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Fax | 703-876-0163
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Provider Business Mailing Address
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Address Line | 3025 HAMAKER CT SUITE # 101
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City | FAIRFAX
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State | VA
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Zip | 22031-2237
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Country | US
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Telephone | 703-876-9630
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Fax | 703-876-0163
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618000912
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License Number State | VA
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