Healthcare Provider Details

I. General information

NPI: 1588865653
Provider Name (Legal Business Name): LUIS C RADICE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4480 KING ST
ALEXANDRIA VA
22302
US

IV. Provider business mailing address

1450 MCLEAN MEWS CT
MCLEAN VA
22101
US

V. Phone/Fax

Practice location:
  • Phone: 703-838-4400
  • Fax:
Mailing address:
  • Phone: 703-442-8057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number0101019625
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: