Healthcare Provider Details

I. General information

NPI: 1659490142
Provider Name (Legal Business Name): DIANA J SLAVIN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA GOLDBERG

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 CENTREVILLE RD STE 100
CHANTILLY VA
20151-3280
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 703-830-6380
  • Fax: 703-263-2441
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number0618001098
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001098
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: