Healthcare Provider Details

I. General information

NPI: 1194960252
Provider Name (Legal Business Name): ALEXANDRIA LAKE RIDGE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N BEAUREGARD ST SUITE 200
ALEXANDRIA VA
22311-1723
US

IV. Provider business mailing address

1707 OSAGE ST SUITE 104
ALEXANDRIA VA
22302-2607
US

V. Phone/Fax

Practice location:
  • Phone: 703-212-6600
  • Fax: 703-931-0961
Mailing address:
  • Phone: 703-212-6600
  • Fax: 703-931-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101038289
License Number StateVA

VIII. Authorized Official

Name: DR. JON M FARBER
Title or Position: TREASURER
Credential: MD
Phone: 703-212-6600