Provider Demographics
NPI:1578524096
Name:CONNESS-JABLONSKI, DIANE MARY (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARY
Last Name:CONNESS-JABLONSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:CONNESS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:12444 DILLINGHAM SQ
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5258
Mailing Address - Country:US
Mailing Address - Phone:703-680-4323
Mailing Address - Fax:703-680-4358
Practice Address - Street 1:12444 DILLINGHAM SQ
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5258
Practice Address - Country:US
Practice Address - Phone:703-680-4323
Practice Address - Fax:703-680-4358
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000204152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA965551OtherAETNA HMO ID#
VA211872OtherUNITED HEALTHCARE/OPT CH.
VA4308449OtherAETNA PPO ID#
VA031111OtherBLUE CROSS BLUE SHIELD ID
VA54-1330725OtherCIGNA
VA54-1330725OtherTRICARE ID #
VA1744962OtherAETNA HMO
VA22-00012OtherUNITEDHEALTHCARE
VA54-1330725OtherCIGNA
VACO2323Medicare ID - Type UnspecifiedGROUP MEDICARE ID#
VA410000244Medicare PIN