Provider Demographics
NPI:1457498602
Name:MALVITZ-OVERLY, CYNTHIA A (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:A
Last Name:MALVITZ-OVERLY
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:MALVITZ
Other - Suffix:
Other - Last Name Type:Other Name
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:571-223-6780
Practice Address - Street 1:1515 6TH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-2272
Practice Address - Country:US
Practice Address - Phone:920-499-2147
Practice Address - Fax:920-499-0574
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2511-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2511-035OtherSTATE LICENSE #
WIMO0348943OtherDEA#
WIMO0348943OtherDEA#