Healthcare Provider Details

I. General information

NPI: 1366570400
Provider Name (Legal Business Name): FAMILY PHYSICIANS OF OLD TOWN FAIRFAX PC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 BLENHEIM BLVD STE 41C
FAIRFAX VA
22030-2434
US

IV. Provider business mailing address

3911 BLENHEIM BLVD STE 41C
FAIRFAX VA
22030-2434
US

V. Phone/Fax

Practice location:
  • Phone: 703-352-7100
  • Fax: 703-539-8579
Mailing address:
  • Phone: 703-352-7100
  • Fax: 703-539-8579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101043356
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID DRAKE LEONARD
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 703-352-7100