Healthcare Provider Details

I. General information

NPI: 1649613902
Provider Name (Legal Business Name): SUMERTA MANCHANDANI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 11/27/2023
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 ARLINGTON BLVD STE G1
FAIRFAX VA
22031-5209
US

IV. Provider business mailing address

8300 ARLINGTON BLVD STE G1
FAIRFAX VA
22031-5209
US

V. Phone/Fax

Practice location:
  • Phone: 571-306-1481
  • Fax:
Mailing address:
  • Phone: 571-306-1481
  • Fax: 571-512-5820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number0101257282
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: