Provider Demographics
NPI:1639177108
Name:THELEN, COURTNEY D (OD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:D
Last Name:THELEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7540 LITTLE RIVER TPKE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2839
Mailing Address - Country:US
Mailing Address - Phone:703-941-4111
Mailing Address - Fax:703-941-3929
Practice Address - Street 1:7630 LITTLE RIVER TPKE STE 100
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2614
Practice Address - Country:US
Practice Address - Phone:703-941-4111
Practice Address - Fax:703-941-3929
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA061800120152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
U76211Medicare UPIN
VA00B247M22Medicare ID - Type Unspecified