Provider Demographics
NPI:1295263234
Name:MAXIMEYES VISION SOURCE, LLC
Entity type:Organization
Organization Name:MAXIMEYES VISION SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-691-7584
Mailing Address - Street 1:1390 CHAIN BRIDGE RD # 313
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3904
Mailing Address - Country:US
Mailing Address - Phone:703-691-7584
Mailing Address - Fax:
Practice Address - Street 1:11011 LEE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5002
Practice Address - Country:US
Practice Address - Phone:703-691-7584
Practice Address - Fax:703-591-6271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-02
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0618002092OtherOPTOMETRY TPA LICENSE