Healthcare Provider Details

I. General information

NPI: 1417006057
Provider Name (Legal Business Name): NICK NEAGLE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 MASSACHUSETTS AVE NW
WASHINGTON DC
20001-3796
US

IV. Provider business mailing address

1950 OLD GALLOWS RD SUITE 520
VIENNA VA
22182-3990
US

V. Phone/Fax

Practice location:
  • Phone: 202-898-1060
  • Fax: 202-898-0472
Mailing address:
  • Phone: 703-847-8899
  • Fax: 703-991-0514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberI3-0001265
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP532
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: