Basic Information
| Provider Information | |||||||||
| NPI: | 1669483301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | LILA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O. D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLAND-CANTRELL | ||||||||
| OtherFirstName: | LILA | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 10050 BALTIMORE NATIONAL PIKE | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210423501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104612020 | ||||||||
| FaxNumber: | 4104612387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 01/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2210 | MD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | TA2210 | 01 | MD | OPTOMETRY LICENSE | OTHER |