Provider Demographics
NPI:1902808181
Name:ATHELLI, JEETANDRA M (OD)
Entity Type:Individual
Prefix:DR
First Name:JEETANDRA
Middle Name:M
Last Name:ATHELLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HOLIDAY CT 207
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-4349
Mailing Address - Country:US
Mailing Address - Phone:540-347-2217
Mailing Address - Fax:540-347-0801
Practice Address - Street 1:14161A ROBERT PARIS CT
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-4204
Practice Address - Country:US
Practice Address - Phone:703-631-0014
Practice Address - Fax:703-449-8770
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA437150OtherANTHEMBLUECROSSBLUESHIELD
VA990003364Medicare PIN
VAU53054Medicare UPIN
VAP01022613Medicare PIN
VA064948Medicare PIN
VA437150OtherANTHEMBLUECROSSBLUESHIELD