Provider Demographics
NPI:1649347600
Name:CASSIDY, DOUGLAS LEONARD (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LEONARD
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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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:571-223-6780
Practice Address - Street 1:4655 MONTICELLO AVE STE 201
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-8221
Practice Address - Country:US
Practice Address - Phone:757-259-6823
Practice Address - Fax:757-259-6826
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001111152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U13899Medicare UPIN