Provider Demographics
NPI:1871089714
Name:BOUGHMAN, MEGAN CHRISTINE (OD)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:CHRISTINE
Last Name:BOUGHMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:860 SUMMIT CROSSING PL STE 110
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2217
Practice Address - Country:US
Practice Address - Phone:704-865-3937
Practice Address - Fax:704-865-8851
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2520152W00000X
SC2077152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist