Healthcare Provider Details

I. General information

NPI: 1487307864
Provider Name (Legal Business Name): JUSTIN TRUMBULL OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N GEORGE MASON DR
ARLINGTON VA
22205-3610
US

IV. Provider business mailing address

1701 N GEORGE MASON DR
ARLINGTON VA
22205-3610
US

V. Phone/Fax

Practice location:
  • Phone: 703-558-6507
  • Fax:
Mailing address:
  • Phone: 703-558-6507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2305208044
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: