Healthcare Provider Details

I. General information

NPI: 1730116658
Provider Name (Legal Business Name): FREDRIC BRUCE GARNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 12/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8988 FERN PARK DR
BURKE VA
22015-1635
US

IV. Provider business mailing address

8988 FERN PARK DR
BURKE VA
22015-1635
US

V. Phone/Fax

Practice location:
  • Phone: 703-978-6061
  • Fax: 703-978-0291
Mailing address:
  • Phone: 703-978-6061
  • Fax: 703-978-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101017927
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: