Basic Information
| Provider Information | |||||||||
| NPI: | 1790805554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRAVDA | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PRAVDA | ||||||||
| OtherFirstName: | JAY | ||||||||
| OtherMiddleName: | S. | ||||||||
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| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| 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: | 20811 HIGHWAY 59 N | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773382259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814462020 | ||||||||
| FaxNumber: | 2815483411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2295TG | TX | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.