Provider Demographics
NPI:1003134248
Name:MATTERN, RUSSELL HALE (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:HALE
Last Name:MATTERN
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 1:2700 POTOMAC MILLS CIR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4625
Mailing Address - Country:US
Mailing Address - Phone:703-490-5275
Mailing Address - Fax:
Practice Address - Street 1:2700 POTOMAC MILLS CIR
Practice Address - Street 2:SUITE 207
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4625
Practice Address - Country:US
Practice Address - Phone:703-490-5275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601000964152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist