Provider Demographics
NPI:1073593059
Name:DRISCOLL, JUDITH ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:ANN
Last Name:DRISCOLL
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 1:5832 OAKLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2440
Mailing Address - Country:US
Mailing Address - Phone:703-250-7320
Mailing Address - Fax:
Practice Address - Street 1:MAIN STREET OPTICAL, 219 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301
Practice Address - Country:US
Practice Address - Phone:413-772-0999
Practice Address - Fax:413-772-5999
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000921152W00000X
MA4285152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAV07091Medicare UPIN
MADR-W17608Medicare ID - Type Unspecified