Provider Demographics
NPI:1750512257
Name:JEFFREY I WYNN OD LTD
Entity Type:Organization
Organization Name:JEFFREY I WYNN OD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-221-3575
Mailing Address - Street 1:17614 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-2359
Mailing Address - Country:US
Mailing Address - Phone:703-221-3575
Mailing Address - Fax:703-221-4416
Practice Address - Street 1:17614 MAIN ST
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22026-2359
Practice Address - Country:US
Practice Address - Phone:703-221-3575
Practice Address - Fax:703-221-4416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000150152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9203265Medicaid
T21664OtherUPIN