Healthcare Provider Details

I. General information

NPI: 1093828147
Provider Name (Legal Business Name): NINA PHATAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 IVY RD STE 220
CHARLOTTESVILLE VA
22903-4968
US

IV. Provider business mailing address

6812 SORREL ST
MC LEAN VA
22101-1526
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-3710
  • Fax: 844-948-9372
Mailing address:
  • Phone: 703-999-2309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101240340
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: