Provider Demographics
NPI:1295085264
Name:VISION ICONIQUE
Entity type:Organization
Organization Name:VISION ICONIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NADIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTAYISIRE
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MPH
Authorized Official - Phone:443-895-4528
Mailing Address - Street 1:6080 FALLS RD
Mailing Address - Street 2:LL1
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2230
Mailing Address - Country:US
Mailing Address - Phone:443-895-4528
Mailing Address - Fax:
Practice Address - Street 1:6080 FALLS RD
Practice Address - Street 2:LL1
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2230
Practice Address - Country:US
Practice Address - Phone:443-895-4528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD257269Medicare PIN