Provider Demographics
NPI:1104973205
Name:MATTERN, JAMES W (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:MATTERN
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 1:3025 HAMAKER CT
Mailing Address - Street 2:SUITE # 101
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2237
Mailing Address - Country:US
Mailing Address - Phone:703-876-9630
Mailing Address - Fax:703-876-0163
Practice Address - Street 1:3025 HAMAKER CT STE 101
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2229
Practice Address - Country:US
Practice Address - Phone:703-876-9630
Practice Address - Fax:703-876-0163
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000912152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009237071Medicaid
VA00A566C65Medicare ID - Type Unspecified
VA009237071Medicaid