Healthcare Provider Details

I. General information

NPI: 1164779682
Provider Name (Legal Business Name): BENJAMIN I. ENAV, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 PROSPERITY AVE SUITE 260
FAIRFAX VA
22031-4339
US

IV. Provider business mailing address

2700 PROSPERITY AVE SUITE 260
FAIRFAX VA
22031-4339
US

V. Phone/Fax

Practice location:
  • Phone: 571-314-0444
  • Fax: 855-237-3628
Mailing address:
  • Phone: 571-314-0444
  • Fax: 855-237-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number0101243680
License Number StateVA

VIII. Authorized Official

Name: DR. BENJAMIN ENAV
Title or Position: PRESIDENT
Credential: MD
Phone: 571-314-0444