Healthcare Provider Details

I. General information

NPI: 1881156362
Provider Name (Legal Business Name): JEFFREY IRWIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13609 CARROLLTON BLVD STE 11
CARROLLTON VA
23314-3214
US

IV. Provider business mailing address

13609 CARROLLTON BLVD STE 11
CARROLLTON VA
23314-3214
US

V. Phone/Fax

Practice location:
  • Phone: 757-238-8751
  • Fax:
Mailing address:
  • Phone: 757-238-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1881156362
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: