Healthcare Provider Details

I. General information

NPI: 1780608984
Provider Name (Legal Business Name): PHILIP SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 12/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 WILLOW OAKS CORPORATE DR
FAIRFAX VA
22031-4512
US

IV. Provider business mailing address

8221 WILLOW OAKS CORPORATE DR
FAIRFAX VA
22031-4512
US

V. Phone/Fax

Practice location:
  • Phone: 703-207-7818
  • Fax: 703-653-6692
Mailing address:
  • Phone: 703-207-7818
  • Fax: 703-653-6692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD034477
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101058192
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: