Healthcare Provider Details

I. General information

NPI: 1689632028
Provider Name (Legal Business Name): CANDACE FUGATE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3914 CENTREVILLE RD STE 101
CHANTILLY VA
20151-3289
US

IV. Provider business mailing address

3914 CENTREVILLE RD
CHANTILLY VA
20151-3289
US

V. Phone/Fax

Practice location:
  • Phone: 703-481-8600
  • Fax: 703-481-8618
Mailing address:
  • Phone: 703-481-8600
  • Fax: 855-308-2338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101057927
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: