Healthcare Provider Details

I. General information

NPI: 1831647239
Provider Name (Legal Business Name): FAIRFAX INTERNAL MEDICINE AND PRIMARY CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5618 OX RD SUITE D-2
FAIRFAX STATION VA
22039
US

IV. Provider business mailing address

5618 OX RD SUITE D-2
FAIRFAX STATION VA
22039
US

V. Phone/Fax

Practice location:
  • Phone: 703-291-0405
  • Fax: 703-337-0377
Mailing address:
  • Phone: 703-291-0405
  • Fax: 703-337-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101250312
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARUNA GALLA
Title or Position: PHYSICIAN
Credential: M.D
Phone: 703-291-0405