Healthcare Provider Details

I. General information

NPI: 1831248731
Provider Name (Legal Business Name): LINO CUETO MONTILLA M.D.,F.A.C.O.G.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 JOSEPH SIEWICK DR SUITE 203
FAIRFAX VA
22033-1710
US

IV. Provider business mailing address

2028 OPITZ BLVD SUITE ONE
WOODBRIDGE VA
22191-3306
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-1500
  • Fax: 703-860-1549
Mailing address:
  • Phone: 703-690-2295
  • Fax: 703-690-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101052618
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: