Healthcare Provider Details

I. General information

NPI: 1386625259
Provider Name (Legal Business Name): ETHRIDGE JUNE LOVETT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 GEORGIA AVE NW
WASHINGTON DC
20307-0003
US

IV. Provider business mailing address

8427 MASTERS CT
ALEXANDRIA VA
22308-2226
US

V. Phone/Fax

Practice location:
  • Phone: 202-785-9513
  • Fax: 202-782-5452
Mailing address:
  • Phone: 202-782-9513
  • Fax: 202-782-5452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101045140
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: