Provider Demographics
NPI:1417006057
Name:NEAGLE, NICK (OD)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:
Last Name:NEAGLE
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:650 MASSACHUSETTS AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-3796
Practice Address - Country:US
Practice Address - Phone:202-898-1060
Practice Address - Fax:202-898-0472
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001265152W00000X
DCOP532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001138722Medicaid
DE0001138722Medicaid
DCUO5840Medicare UPIN
021241A60Medicare PIN