Provider Demographics
NPI:1538311204
Name:WESTERN MARYLAND VISION ASSOCIATES
Entity type:Organization
Organization Name:WESTERN MARYLAND VISION ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:PESTA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:301-729-4242
Mailing Address - Street 1:1221B NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7602
Mailing Address - Country:US
Mailing Address - Phone:301-729-4242
Mailing Address - Fax:301-729-8636
Practice Address - Street 1:1221B NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7602
Practice Address - Country:US
Practice Address - Phone:301-729-4242
Practice Address - Fax:301-729-8636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MARYLAND VISION ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-14
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1712152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5451640001Medicare NSC