Provider Demographics
NPI:1710069950
Name:NORTHERN VIRGINIA VISION CENTER, INC.
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA VISION CENTER, INC.
Other - Org Name:THE EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-430-4400
Mailing Address - Street 1:21475 RIDGETOP CIR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-6580
Mailing Address - Country:US
Mailing Address - Phone:703-430-4400
Mailing Address - Fax:703-430-4130
Practice Address - Street 1:21475 RIDGETOP CIRCLE
Practice Address - Street 2:SUITE 300
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-6580
Practice Address - Country:US
Practice Address - Phone:703-430-4400
Practice Address - Fax:703-430-4130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618-000230152W00000X
VA0101-043806207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0858550001OtherDEMERC STERLING OFFICE
DC4147OtherBCBS NCA/CAPITAL CARE
VA0858550003OtherDEMERC FAIRFAX OFFICE
VA0858550002OtherDEMERC ALEXANDRIA OFFICE
VA0858550004OtherDEMERC LEESBURG OFFICE
MD8956502Medicaid
VA=========OtherCIGNA PPO GROUP #
VA0858550002OtherDEMERC ALEXANDRIA OFFICE
VA0858550004OtherDEMERC LEESBURG OFFICE
VA=========OtherKAISER GROUP #
DC4147OtherBCBS NCA/CAPITAL CARE
VA=========-002OtherCHAMPUS ALEXANDRIA OFFICE
VA=========-003OtherCHAMPUS FAIRFAX OFFICE