Basic Information
| Provider Information | |||||||||
| NPI: | 1023190030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATCHUK | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7039910514 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 EAST WEST HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016560775 | ||||||||
| FaxNumber: | 3016565164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618001165 | VA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | TA-1679 | MD | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.