Healthcare Provider Details

I. General information

NPI: 1124370093
Provider Name (Legal Business Name): FAIRFAX PULMONARY CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 N POLLARD ST #501
ARLINGTON VA
22203-1738
US

IV. Provider business mailing address

880 N POLLARD ST #501
ARLINGTON VA
22203-1738
US

V. Phone/Fax

Practice location:
  • Phone: 703-957-9119
  • Fax:
Mailing address:
  • Phone: 703-957-9119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0116019977
License Number StateVA

VIII. Authorized Official

Name: DR. JEFFREY ONEIL DIMITRY WILLIAMS
Title or Position: MEMBER
Credential: MD
Phone: 703-957-9119