Basic Information
| Provider Information | |||||||||
| NPI: | 1740208941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCIFRES | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TODD | ||||||||
| OtherFirstName: | ANGELA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| 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: | 308 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CYNTHIANA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410311210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592341424 | ||||||||
| FaxNumber: | 8592345463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1671DT | KY | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77001592 | 05 | KY | MEDICAID |