Basic Information
| Provider Information | |||||||||
| NPI: | 1467411603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOBRUSIN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | SUITE # 520 | ||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 LONDONTOWN BLVD | ||||||||
| Address2: | SUITE # 100 | ||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217846454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107955588 | ||||||||
| FaxNumber: | 4107955648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 01/30/2018 | ||||||||
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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 | TA0656 | MD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3573538 | 05 | MD | MEDICAID |