Organization
MAXIMEYES VISION SOURCE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARIA PHAM OD (OPTOMETRIST/OWNER)
(703) 691-7584
Entity
Organization
Contact information
Practice address
11011 LEE HWY, FAIRFAX, VA 22030-5002
(703) 691-7584
(703) 591-6271
Mailing address
1390 CHAIN BRIDGE RD # 313, MC LEAN, VA 22101-3904
(703) 691-7584
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
0618002092
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0618002092
OPTOMETRY TPA LICENSE
VA
Enumeration date
06/02/2017
Last updated
06/20/2017
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