Provider Demographics
NPI:1104037977
Name:NOVA EYE PHYSICIANS & SURGEONS
Entity Type:Organization
Organization Name:NOVA EYE PHYSICIANS & SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:Q
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-339-4630
Mailing Address - Street 1:505 PLANTATION ST
Mailing Address - Street 2:#412
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-4333
Mailing Address - Country:US
Mailing Address - Phone:703-200-6804
Mailing Address - Fax:
Practice Address - Street 1:3223 DUKE ST
Practice Address - Street 2:SUITE G
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4586
Practice Address - Country:US
Practice Address - Phone:703-200-6804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234485207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAI41830Medicare UPIN