Provider Demographics
NPI:1811065469
Name:HASKINS, DIANA L (OD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:L
Last Name:HASKINS
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:571-223-6780
Practice Address - Street 1:1761 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-6101
Practice Address - Country:US
Practice Address - Phone:269-934-0424
Practice Address - Fax:269-934-0570
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008855152WC0802X
MI4901004811152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1811065469Medicaid
MI0C97655Medicare PIN
MI07335000Medicare PIN