Healthcare Provider Details

I. General information

NPI: 1588059273
Provider Name (Legal Business Name): BERHANEMESKEL A NIDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BERHAN ALEMU NIDA M.D.

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 WILLOW OAKS CORPORATE DR STE 200
FAIRFAX VA
22031-4515
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101269004
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: