Provider Demographics
NPI:1780117572
Name:FARDINK, JEFFREY R (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:FARDINK
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 1:5617 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2614
Mailing Address - Country:US
Mailing Address - Phone:804-282-7228
Mailing Address - Fax:804-285-3781
Practice Address - Street 1:5617 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2614
Practice Address - Country:US
Practice Address - Phone:804-282-7228
Practice Address - Fax:804-285-3781
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist