Healthcare Provider Details

I. General information

NPI: 1043243728
Provider Name (Legal Business Name): OLYMPIA P DALLAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 UNIVERSITY DR MS 2D3 GEORGE MASON UNIVERSITY STUDENT HEALTH
FAIRFAX VA
22030
US

IV. Provider business mailing address

4400 UNIVERSITY DR MS 2D3 GEORGE MASON UNIVERSITY STUDENT HEALTH
FAIRFAX VA
22030
US

V. Phone/Fax

Practice location:
  • Phone: 703-993-2807
  • Fax: 703-993-4365
Mailing address:
  • Phone: 703-993-2807
  • Fax: 703-993-4365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101033600
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: