Provider Demographics
NPI:1093709594
Name:DEOLA, JERRY J (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:J
Last Name:DEOLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 DALE BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-2534
Mailing Address - Country:US
Mailing Address - Phone:703-670-8085
Mailing Address - Fax:
Practice Address - Street 1:4460 DALE BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2534
Practice Address - Country:US
Practice Address - Phone:703-670-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601000801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009204041Medicaid
VA009204041Medicaid
T30971Medicare UPIN