Provider Demographics
NPI:1336153006
Name:DELCAMPO, MARY ELIZA V (OD)
Entity Type:Individual
Prefix:
First Name:MARY ELIZA
Middle Name:V
Last Name:DELCAMPO
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
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:866-795-4020
Practice Address - Street 1:9400 ATLANTIC BLVD
Practice Address - Street 2:SUITE 62
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225
Practice Address - Country:US
Practice Address - Phone:904-721-7700
Practice Address - Fax:904-721-0051
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3333152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620947500Medicaid
FLU78965Medicare UPIN
FLE3632ZMedicare PIN
FLU78965Medicare UPIN