Provider Demographics
NPI:1871674622
Name:WAYLAND, DAVID JACKSON SR (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JACKSON
Last Name:WAYLAND
Suffix:SR
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:STE 520
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:703-991-0514
Practice Address - Street 1:3975 OLD MILTON PKWY
Practice Address - Street 2:STE2
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4467
Practice Address - Country:US
Practice Address - Phone:678-624-7766
Practice Address - Fax:678-624-7775
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2018-02-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GAOPT001624152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00919322AMedicaid
GA00919322AMedicaid