Healthcare Provider Details

I. General information

NPI: 1003632373
Provider Name (Legal Business Name): GASTRO VIRGINIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12011 ROUTE 50 STE 506
FAIRFAX VA
22033-3315
US

IV. Provider business mailing address

7120 MINSTREL WAY STE 100
COLUMBIA MD
21045-5274
US

V. Phone/Fax

Practice location:
  • Phone: 484-339-6869
  • Fax: 484-214-9609
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: ZACHARY JONES
Title or Position: CEO
Credential:
Phone: 207-631-7837