Healthcare Provider Details

I. General information

NPI: 1902293210
Provider Name (Legal Business Name): JONATHAN IRA SEGAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 MARK CENTER DR STE 150
ALEXANDRIA VA
22311-1846
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 703-751-8111
  • Fax: 703-751-1105
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101273918
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number0101273918
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101273918
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: