Provider Demographics
NPI:1932130945
Name:KOLLIAS, JODI (OD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:
Last Name:KOLLIAS
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 1:2955 CRAIN HWY
Mailing Address - Street 2:SUITE A&B
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-2810
Mailing Address - Country:US
Mailing Address - Phone:301-843-1000
Mailing Address - Fax:301-843-1919
Practice Address - Street 1:2955 CRAIN HWY
Practice Address - Street 2:SUITE A&B
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2810
Practice Address - Country:US
Practice Address - Phone:301-843-1000
Practice Address - Fax:301-843-1919
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOP1000106152W00000X
MDTA1954152W00000X
VA0618001486152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD747LM823Medicare PIN
MDV07417Medicare UPIN