Healthcare Provider Details

I. General information

NPI: 1568706158
Provider Name (Legal Business Name): BOULEVARD CENTER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3733 FETTLER PARK DR.
DUMFRIES VA
22025
US

IV. Provider business mailing address

3733 FETTLER PARK DR.
DUMFRIES VA
22025
US

V. Phone/Fax

Practice location:
  • Phone: 703-670-0300
  • Fax: 703-291-5331
Mailing address:
  • Phone: 703-670-0300
  • Fax: 703-291-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101244499
License Number StateVA

VIII. Authorized Official

Name: ANITA GOHEL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 703-670-0300