Basic Information
| Provider Information | |||||||||
| NPI: | 1033268842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | HOPPS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 N TOWN EAST BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751504705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722792020 | ||||||||
| FaxNumber: | 9722792637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 2364TG | TX | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | 2364 | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 019968901 | 05 | TX | MEDICAID | 2364TG | 01 | TX | STATE LICENSE NUMBER | OTHER |