1386719524 NPI number — HISPANIC AMERICAN PEDIATRIC ASSOCIATES

Table of content: (NPI 1386719524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386719524 NPI number — HISPANIC AMERICAN PEDIATRIC ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HISPANIC AMERICAN PEDIATRIC ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386719524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5130 DUKE ST STE 7
Provider Second Line Business Mailing Address:
SUITE 229
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22304-2955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-751-2021
Provider Business Mailing Address Fax Number:
703-751-2071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5130 DUKE STREET
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22304-7207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-751-2021
Provider Business Practice Location Address Fax Number:
703-751-2071
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OMIDVAR
Authorized Official First Name:
JEMAL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-751-2021

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  40990-01 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010117534 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002632800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010125561 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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