=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558743708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYEYEDR OPTOMETRY OF MARYLAND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2015
-----------------------------------------------------
Last Update Date | 05/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 951F BEARDS HILL RD
-----------------------------------------------------
City | ABERDEEN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21001-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-272-1800
-----------------------------------------------------
Fax | 410-272-5873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8614 WESTWOOD CENTER DR FL 9
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-2442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-847-8899
-----------------------------------------------------
Fax | 571-223-6780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | SUE HEALEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-847-8899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------