Provider Demographics
NPI:1225075732
Name:RECORD, STEPHEN WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WAYNE
Last Name:RECORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:1450 SACHEM PL
Practice Address - Street 2:STE 202
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-2554
Practice Address - Country:US
Practice Address - Phone:434-978-4090
Practice Address - Fax:434-978-1005
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000233152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA113326OtherANTHEM BC/BS
VA410000990Medicare ID - Type Unspecified
VAT21837Medicare UPIN