Basic Information
| Provider Information | |||||||||
| NPI: | 1659684595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETCOV | ||||||||
| FirstName: | VLADISLAV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 NOBLE BLVD STE 120 | ||||||||
| Address2: | |||||||||
| City: | CARLISLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170134122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172186656 | ||||||||
| FaxNumber: | 7172430738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2010 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG002362 | PA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.