Provider Demographics
NPI:1669483301
Name:GOODWIN, LILA ANNE (O D)
Entity type:Individual
Prefix:DR
First Name:LILA
Middle Name:ANNE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:O D
Other - Prefix:DR
Other - First Name:LILA
Other - Middle Name:ANNE
Other - Last Name:MILLAND-CANTRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
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 1:10050 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3501
Practice Address - Country:US
Practice Address - Phone:410-461-2020
Practice Address - Fax:410-461-2387
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDTA2210OtherOPTOMETRY LICENSE