Provider Demographics
NPI:1215626015
Name:IKONOMOV, LUBEN METODIEV (OD)
Entity type:Individual
Prefix:DR
First Name:LUBEN
Middle Name:METODIEV
Last Name:IKONOMOV
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 1:1593 VERMONT ROUTE 107
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:VT
Mailing Address - Zip Code:05032-4456
Mailing Address - Country:US
Mailing Address - Phone:802-234-9728
Mailing Address - Fax:802-234-9728
Practice Address - Street 1:1593 VERMONT ROUTE 107
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:VT
Practice Address - Zip Code:05032-4456
Practice Address - Country:US
Practice Address - Phone:802-234-9728
Practice Address - Fax:802-234-9728
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0133986152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty