Provider Demographics
NPI:1033917000
Name:COLLAZOS QUIROGA, LEADY DALLAN (OPTOMETRIST)
Entity type:Individual
Prefix:
First Name:LEADY
Middle Name:DALLAN
Last Name:COLLAZOS QUIROGA
Suffix:
Gender:F
Credentials:OPTOMETRIST
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:504-432-4692
Mailing Address - Fax:703-923-5043
Practice Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2442
Practice Address - Country:US
Practice Address - Phone:504-432-4692
Practice Address - Fax:703-923-5043
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC152W00000X152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty