Provider Demographics
NPI:1700970522
Name:CARLYLE, AMY E (OD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:CARLYLE
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 1:8721 DIGGES RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4403
Mailing Address - Country:US
Mailing Address - Phone:703-361-4161
Mailing Address - Fax:
Practice Address - Street 1:8721 DIGGES RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4403
Practice Address - Country:US
Practice Address - Phone:703-361-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000658152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9233865Medicaid
VA9233865Medicaid