Provider Demographics
NPI:1235193806
Name:ADAM, ENDER ALI (OD)
Entity Type:Individual
Prefix:
First Name:ENDER
Middle Name:ALI
Last Name:ADAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8350 TRAFORD LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1638
Mailing Address - Country:US
Mailing Address - Phone:703-569-6363
Mailing Address - Fax:703-569-3536
Practice Address - Street 1:8350 TRAFORD LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1638
Practice Address - Country:US
Practice Address - Phone:703-569-6363
Practice Address - Fax:703-569-3536
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000251152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9234446Medicaid
VA9234446Medicaid
D77M97Medicare ID - Type Unspecified