Healthcare Provider Details

I. General information

NPI: 1013111913
Provider Name (Legal Business Name): DR. MICHAEL JOSE ARDAIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6428 LEE HWY
ARLINGTON VA
22205-1922
US

IV. Provider business mailing address

6428 LEE HWY
ARLINGTON VA
22205-1922
US

V. Phone/Fax

Practice location:
  • Phone: 703-447-8723
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberMD30604
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: