=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184813172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN VIRGINIA VISION CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2007
-----------------------------------------------------
Last Update Date | 10/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8316 ARLINGTON BLVD SUITE 235
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-573-8080
-----------------------------------------------------
Fax | 703-573-2929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8316 ARLINGTON BLVD SUITE 235
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-573-8080
-----------------------------------------------------
Fax | 703-573-2929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AYMAN BOUTROS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 703-573-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 0101043806
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------