Provider Demographics
NPI:1003074139
Name:BERTOMEU, VINCENT A (OD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:A
Last Name:BERTOMEU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:1841 FOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3326
Practice Address - Country:US
Practice Address - Phone:703-264-2020
Practice Address - Fax:703-481-9474
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2088152W00000X
DCOP1000240152W00000X
VA0618001167152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003074139Medicaid
VA1003074139Medicaid