Provider Demographics
NPI:1104568708
Name:FAYCHAK, KAMERON
Entity type:Individual
Prefix:
First Name:KAMERON
Middle Name:
Last Name:FAYCHAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:22 MCINTYRE SQUARE DR
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-7301
Practice Address - Country:US
Practice Address - Phone:412-364-4700
Practice Address - Fax:412-364-4628
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOEG003918152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program