Healthcare Provider Details

I. General information

NPI: 1174614655
Provider Name (Legal Business Name): MICHAEL JAY NATHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 SHERWOOD HALL LN SUITE 411
ALEXANDRIA VA
22306-3100
US

IV. Provider business mailing address

2616 SHERWOOD HALL LN SUITE 411
ALEXANDRIA VA
22306-3100
US

V. Phone/Fax

Practice location:
  • Phone: 703-780-5073
  • Fax:
Mailing address:
  • Phone: 703-780-5073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101042969
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: