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NPI Code Detail

MEDICARE: DR. KESTON MICAH REGIS O.D.

MEDICARE: DR. KESTON MICAH REGIS 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
1152W00000XOptometristTA2378MD

General Provider Information

NPI Number : 1760816755
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KESTON MICAH REGIS O.D.
Provider Business Mailing Address
First Line : 1950 OLD GALLOWS RD STE 520
Second Line :
City : VIENNA
State : VA
Zip : 22182-3970
Country : US
Telephone Number : 703-847-8899
Fax Number : 866-795-4020
Provider Business Practice Location Address
First Line : 3309 FORESTVILLE PL
Second Line :
City : FORESTVILLE
State : MD
Zip : 20747-4409
Country : US
Telephone Number : 301-420-6610
Fax Number : 301-735-0294
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2013
Last Update Date : 01/31/2018

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