Provider Demographics
NPI: | 1477515237 |
---|---|
Name: | ASTRUC, JUAN ANTONIO JR (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JUAN |
Middle Name: | ANTONIO |
Last Name: | ASTRUC |
Suffix: | JR |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 8720 STONY POINT PKWY STE 105 |
Mailing Address - Street 2: | |
Mailing Address - City: | RICHMOND |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 23235-1989 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 804-644-7478 |
Mailing Address - Fax: | 804-644-8224 |
Practice Address - Street 1: | 8720 STONY POINT PKWY STE 105 |
Practice Address - Street 2: | |
Practice Address - City: | RICHMOND |
Practice Address - State: | VA |
Practice Address - Zip Code: | 23235-1989 |
Practice Address - Country: | US |
Practice Address - Phone: | 804-644-7478 |
Practice Address - Fax: | 804-644-8224 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-05 |
Last Update Date: | 2021-01-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0101056271 | 207WX0107X, 207W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | |
No | 207WX0107X | Allopathic & Osteopathic Physicians | Ophthalmology | Retina Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 6309801 | Medicaid | |
180000931 | Medicare PIN | ||
H25237 | Medicare UPIN |