Provider Demographics
NPI:1265194245
Name:AZOCAR, SEBASTHIAN THOMAS (OD)
Entity type:Individual
Prefix:
First Name:SEBASTHIAN
Middle Name:THOMAS
Last Name:AZOCAR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:SEBASTHIAN
Other - Middle Name:THOMAS
Other - Last Name:AHUMADA AZOCAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:10116 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-6514
Mailing Address - Country:US
Mailing Address - Phone:804-515-7733
Mailing Address - Fax:
Practice Address - Street 1:10116 BROOK RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-6514
Practice Address - Country:US
Practice Address - Phone:804-515-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618003079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist