Provider Demographics
NPI:1083878417
Name:FANG, VICKIE (OD)
Entity Type:Individual
Prefix:DR
First Name:VICKIE
Middle Name:
Last Name:FANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3506
Mailing Address - Country:US
Mailing Address - Phone:301-556-1973
Mailing Address - Fax:301-556-1968
Practice Address - Street 1:880 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3506
Practice Address - Country:US
Practice Address - Phone:301-556-1973
Practice Address - Fax:301-556-1968
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDA1359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist