Healthcare Provider Details

I. General information

NPI: 1508841529
Provider Name (Legal Business Name): JOHN WESLEY HARIADI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WILSON BLVD SUITE 950
ARLINGTON VA
22203-1800
US

IV. Provider business mailing address

4200 WILSON BLVD SUITE 950
ARLINGTON VA
22203-1800
US

V. Phone/Fax

Practice location:
  • Phone: 202-493-1226
  • Fax: 202-443-1739
Mailing address:
  • Phone: 202-493-1226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-10569
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number00024831
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: