Healthcare Provider Details

I. General information

NPI: 1063710515
Provider Name (Legal Business Name): ROBERT EDWARD MACDONNELL OCCUPATIONAL THERAPI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 FETTLER PARK DUMFRIES HEALTH CENTER
DUMFRIES VA
22025
US

IV. Provider business mailing address

3700 FETTLER PARK DUMFRIES HEALTH CENTER
DUMFRIES VA
22025
US

V. Phone/Fax

Practice location:
  • Phone: 703-441-7500
  • Fax:
Mailing address:
  • Phone: 703-441-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0119002314
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: