Healthcare Provider Details

I. General information

NPI: 1982672937
Provider Name (Legal Business Name): IVAN AKSENTIJEVICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE STE 1018
ALEXANDRIA VA
22304-1306
US

IV. Provider business mailing address

3040 WILLIAMS DR SUITE 100
FAIRFAX VA
22031-4618
US

V. Phone/Fax

Practice location:
  • Phone: 571-483-1800
  • Fax: 703-823-5723
Mailing address:
  • Phone: 703-208-3963
  • Fax: 703-205-6284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number0101234651
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number0101234651
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0101234651
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: