Provider Demographics
NPI:1205024692
Name:FAIRFAX EYE CENTER, PC
Entity Type:Organization
Organization Name:FAIRFAX EYE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:HARTZELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-801-5833
Mailing Address - Street 1:2916 HIBBARD ST
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-2648
Mailing Address - Country:US
Mailing Address - Phone:508-801-5833
Mailing Address - Fax:703-242-0919
Practice Address - Street 1:3650 JOSEPH SIEWICK DR STE 303
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1714
Practice Address - Country:US
Practice Address - Phone:508-801-5833
Practice Address - Fax:703-242-0919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239520207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA492195OtherMEDICARE PTAN
VA492195OtherMEDICARE PTAN