1720259054 NPI number — FAIRFAX ENT & FACIAL PLASTIC SURGERY, PC

Table of content: (NPI 1720259054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720259054 NPI number — FAIRFAX ENT & FACIAL PLASTIC SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX ENT & FACIAL PLASTIC SURGERY, PC
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:
1720259054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8120 GATEHOUSE RD
Provider Second Line Business Mailing Address:
#3
Provider Business Mailing Address City Name:
FALLS CHURCH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22042-1204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-573-3687
Provider Business Mailing Address Fax Number:
703-204-0114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8120 GATEHOUSE RD
Provider Second Line Business Practice Location Address:
#3
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22042-1204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-573-3687
Provider Business Practice Location Address Fax Number:
703-204-0114
Provider Enumeration Date:
03/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
O'HALLORAN
Authorized Official First Name:
LAURENCE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-573-3687

Provider Taxonomy Codes

  • Taxonomy code: 207YX0007X , with the licence number:  0101051134 , 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)





Copyright © 2007-2025 www.npivalidator.com