=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376127894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESAPEAKE EYE CARE & LASER CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2021
-----------------------------------------------------
Last Update Date | 05/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3025 HAMAKER CT STE 101
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-2229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-876-9630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2002 MEDICAL PKWY STE 200
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-3046
-----------------------------------------------------
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 | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------