Provider Demographics
NPI:1720141757
Name:KORNMAN, GAYLE (OD)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:
Last Name:KORNMAN
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
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:1418 DRESDEN DR NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3598
Practice Address - Country:US
Practice Address - Phone:404-239-0272
Practice Address - Fax:404-239-0298
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3435152W00000X
GAOPT001217152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0393410Medicaid
MAU28033Medicare UPIN
MA453258Medicare ID - Type Unspecified
MA9715070Medicaid
MAW21059Medicare ID - Type UnspecifiedGRPUP NUMBER