=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255813507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESAPEAKE EYE CARE & LASER CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2018
-----------------------------------------------------
Last Update Date | 04/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5454 WISCONSIN AVE STE 1420
-----------------------------------------------------
City | CHEVY CHASE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20815-6961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-571-8733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2002 MEDICAL PKWY STE 320
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-571-8733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIA C SCOTT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 410-571-7998
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------