Healthcare Provider Details

I. General information

NPI: 1215565965
Provider Name (Legal Business Name): FREIDRICH DATU ANSELMO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 HAMAKER CT STE 340
FAIRFAX VA
22031-2237
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 703-849-8036
  • Fax: 703-204-3448
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101279799
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: