MEDICARE: DR. LUBEN METODIEV IKONOMOV O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	030.0133986	VT

General Provider Information

NPI Number	:	1215626015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUBEN METODIEV IKONOMOV O.D.

Provider Business Mailing Address
First Line	:	1593 VERMONT ROUTE 107
Second Line	:
City	:	BETHEL
State	:	VT
Zip	:	05032-4456
Country	:	US
Telephone Number	:	802-234-9728
Fax Number	:	802-234-9728

Provider Business Practice Location Address
First Line	:	1593 VERMONT ROUTE 107
Second Line	:
City	:	BETHEL
State	:	VT
Zip	:	05032-4456
Country	:	US
Telephone Number	:	802-234-9728
Fax Number	:	802-234-9728

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2023
Last Update Date	:	05/08/2023

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Directions to “ DR. LUBEN METODIEV IKONOMOV O.D.” Practice Location

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