Provider Demographics
NPI:1568700714
Name:IDONI, JENNIFER D (OD, FAAO, FCOVD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:D
Last Name:IDONI
Suffix:
Gender:F
Credentials:OD, FAAO, FCOVD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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 1:1960 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1129
Practice Address - Country:US
Practice Address - Phone:704-372-5332
Practice Address - Fax:704-714-5343
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2507152WP0200X, 152W00000X
AZ2083152WP0200X, 152WV0400X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision