Provider Demographics
NPI:1891840617
Name:MAURER, DIANA (OD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MAURER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:2209 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-0902
Practice Address - Country:US
Practice Address - Phone:912-285-2021
Practice Address - Fax:912-285-2558
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA101698OtherAVESIS RUN GA MEDICAID
GA000872781AMedicaid
08529OtherSPECTERA INS ID
41ZCDFCMedicare ID - Type UnspecifiedMEDICARE ID