Provider Demographics
NPI:1740700913
Name:CUNNINGHAM, KARL ETHAN (OD)
Entity type:Individual
Prefix:DR
First Name:KARL
Middle Name:ETHAN
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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 1:1093 ELM ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1505
Practice Address - Country:US
Practice Address - Phone:603-296-0235
Practice Address - Fax:603-296-0242
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0131034152W00000X
NH1052152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist