Provider Demographics
NPI:1861408817
Name:CONDON, DARYL LEE (OD)
Entity type:Individual
Prefix:DR
First Name:DARYL
Middle Name:LEE
Last Name:CONDON
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 1:1950 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:
Practice Address - Street 1:1014 NORTHSIDE DR E STE E
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1002
Practice Address - Country:US
Practice Address - Phone:912-764-9147
Practice Address - Fax:912-764-3250
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008433152W00000X
GAOPT002983152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3208237OtherBC/BS OF IL
ILU32-362Medicare UPIN
IL3208237OtherBC/BS OF IL
IL978880Medicare PIN