Provider Demographics
NPI:1659379345
Name:GAMMON, DAWN DEVANEY (OD)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:DEVANEY
Last Name:GAMMON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:
Other - Last Name:DEVANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:11641 PINE TREE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2714
Mailing Address - Country:US
Mailing Address - Phone:202-409-1385
Mailing Address - Fax:703-865-5438
Practice Address - Street 1:11900 MARKET ST
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5614
Practice Address - Country:US
Practice Address - Phone:703-709-5400
Practice Address - Fax:703-709-7716
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000679152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U69402Medicare UPIN
002977Medicare ID - Type Unspecified