Basic Information
| Provider Information | |||||||||
| NPI: | 1528296456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOREN | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | BRAD | ||||||||
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| Credential: | OD | ||||||||
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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: | 7039910514 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 POTOMAC STATION DR NE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201761817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036694646 | ||||||||
| FaxNumber: | 7039910514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618001843 | VA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.