Provider Demographics
NPI:1548005887
Name:WASHINGTON, DEIONNA BERRY (LDO)
Entity type:Individual
Prefix:
First Name:DEIONNA
Middle Name:BERRY
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13577 30TH ST
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-8302
Mailing Address - Country:US
Mailing Address - Phone:334-652-6737
Mailing Address - Fax:
Practice Address - Street 1:2425 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31503-6337
Practice Address - Country:US
Practice Address - Phone:912-283-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002965156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician