Healthcare Provider Details

I. General information

NPI: 1003178005
Provider Name (Legal Business Name): BRISTOW PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10492 BRISTOW CENTER DR
BRISTOW VA
20136-2202
US

IV. Provider business mailing address

10492 BRISTOW CENTER DR
BRISTOW VA
20136-2202
US

V. Phone/Fax

Practice location:
  • Phone: 571-379-4246
  • Fax: 540-379-4276
Mailing address:
  • Phone: 571-379-4246
  • Fax: 571-379-4276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101234434
License Number StateVA

VIII. Authorized Official

Name: DR. GAIL LYNN DOLAN
Title or Position: OWNER
Credential: M.D.
Phone: 571-379-4246