Provider Demographics
NPI:1194841874
Name:MADISON, MITRA (OD)
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:MADISON
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 1:1669 CARL D SILVER PKWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4934
Mailing Address - Country:US
Mailing Address - Phone:540-548-2345
Mailing Address - Fax:540-548-1222
Practice Address - Street 1:1669 CARL D SILVER PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4934
Practice Address - Country:US
Practice Address - Phone:540-548-2345
Practice Address - Fax:540-548-1222
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist