Healthcare Provider Details

I. General information

NPI: 1427009083
Provider Name (Legal Business Name): JACOB A NINAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
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 STE 100
FAIRFAX VA
22031-4618
US

V. Phone/Fax

Practice location:
  • Phone: 703-208-3155
  • Fax: 703-823-5723
Mailing address:
  • Phone: 571-350-8400
  • Fax: 703-940-8697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0101248453
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: