Healthcare Provider Details

I. General information

NPI: 1144574492
Provider Name (Legal Business Name): GADDIPATI PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24430 MILLSTREAM DR
ALDIE VA
20105-3098
US

IV. Provider business mailing address

PO BOX 2271
FAIRFAX VA
22031-0271
US

V. Phone/Fax

Practice location:
  • Phone: 703-957-2000
  • Fax:
Mailing address:
  • Phone: 703-991-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101246037
License Number StateVA

VIII. Authorized Official

Name: DR. SWAPNA GADDIPATI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 703-991-9778