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General NPI Number Information
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NPI Number | 1912345471
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Entity Type | Organization
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Legal Business Name | CLARKSBURG EYE CARE, LLC
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Dates
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Enumeration Date | 06/06/2013
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Last Update Date | 06/06/2013
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Provider Practice Location Address
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Address Line | 23202 BREWERS TAVERN WAY
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City | CLARKSBURG
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State | MD
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Zip | 20871-4391
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Country | US
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Telephone | 301-972-3937
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Fax |
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Provider Business Mailing Address
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Address Line | 23202 BREWERS TAVERN WAY
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City | CLARKSBURG
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State | MD
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Zip | 20871-4391
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Country | US
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Telephone | 301-972-3937
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. IRVING GAN
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Credential | O.D.
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Telephone | 301-972-3937
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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 | TA1469
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License Number State | MD
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