Provider Demographics
NPI:1770501546
Name:PHILLIPS, CLIFFORD ISAAC (OD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:ISAAC
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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 1:18800 FOREST RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4494
Practice Address - Country:US
Practice Address - Phone:434-385-8800
Practice Address - Fax:434-385-9011
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010050171Medicaid
VA010050189Medicaid
VA010050146Medicaid
VA010050146Medicaid
VA010050171Medicaid