MEDICARE: ANTON VLASOV D.O.

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	207W00000X	Ophthalmology Physician	1489	NE
2	207W00000X	Ophthalmology Physician	2017-02607	NC

General Provider Information

NPI Number	:	1841639564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTON VLASOV D.O.

Provider Business Mailing Address
First Line	:	6200 FAUVETTE LN
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-6443
Country	:	US
Telephone Number	:	248-854-5230
Fax Number	:

Provider Business Practice Location Address
First Line	:	2817 REILLY ST
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-0004
Country	:	US
Telephone Number	:	910-907-6001
Fax Number	:

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

Provider Enumeration Date	:	06/15/2013
Last Update Date	:	04/02/2018

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