Provider Demographics
NPI:1386834620
Name:EYE PLASTIC ASSOCIATES PC
Entity Type:Organization
Organization Name:EYE PLASTIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDMARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-620-4300
Mailing Address - Street 1:3700 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1744
Mailing Address - Country:US
Mailing Address - Phone:703-620-4300
Mailing Address - Fax:703-620-4367
Practice Address - Street 1:3700 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 400
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1744
Practice Address - Country:US
Practice Address - Phone:703-620-4300
Practice Address - Fax:703-620-4367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006305245Medicaid
F05858Medicare UPIN
VA006305245Medicaid