Healthcare Provider Details

I. General information

NPI: 1528358199
Provider Name (Legal Business Name): DANIEL MACLEOD FISTERE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2722 MERRILEE DR STE 230
FAIRFAX VA
22031-4400
US

IV. Provider business mailing address

2722 MERRILEE DR STE 230
FAIRFAX VA
22031-4400
US

V. Phone/Fax

Practice location:
  • Phone: 703-698-4488
  • Fax:
Mailing address:
  • Phone: 703-698-4444
  • Fax: 703-204-0116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101263565
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number287924-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: