Provider Demographics
NPI:1114918943
Name:COLVIN, ANJONETTE L (OD)
Entity Type:Individual
Prefix:DR
First Name:ANJONETTE
Middle Name:L
Last Name:COLVIN
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:571-223-6780
Practice Address - Street 1:9816 N BEACH ST
Practice Address - Street 2:STE 101
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6184
Practice Address - Country:US
Practice Address - Phone:817-741-2020
Practice Address - Fax:817-741-3937
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-01
Last Update Date:2022-05-06
Deactivation Date:2008-06-03
Deactivation Code:
Reactivation Date:2008-08-27
Provider Licenses
StateLicense IDTaxonomies
TX6164TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU99310Medicare PIN
TX8F1780Medicare PIN
TXU99310Medicare UPIN
TXP00323424Medicare PIN
TX8F1780Medicare Oscar/Certification