Healthcare Provider Details

I. General information

NPI: 1700887387
Provider Name (Legal Business Name): THE CLINICAL SKIN CENTER OF NORTHERN VIRGINIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 JOSEPH SIEWICK DR SUITE 404
FAIRFAX VA
22033-1744
US

IV. Provider business mailing address

3700 JOSEPH SIEWICK DR SUITE 404
FAIRFAX VA
22033-1744
US

V. Phone/Fax

Practice location:
  • Phone: 703-620-8900
  • Fax: 703-620-2288
Mailing address:
  • Phone: 703-620-8900
  • Fax: 703-620-2288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101049818
License Number StateVA

VIII. Authorized Official

Name: DR. MITCHELL E. STASHOWER
Title or Position: OWNER
Credential: M.D.
Phone: 703-620-8900