Healthcare Provider Details

I. General information

NPI: 1770022261
Provider Name (Legal Business Name): HECTOR BERMUDEZ CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 YOAKUM PKWY
ALEXANDRIA VA
22304-4052
US

IV. Provider business mailing address

300 YOAKUM PKWY
ALEXANDRIA VA
22304-4052
US

V. Phone/Fax

Practice location:
  • Phone: 301-266-3439
  • Fax:
Mailing address:
  • Phone: 301-266-3439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number4616
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: